{
  "hospital_name": "Demo General Hospital",
  "last_updated_on": "2026-07-17",
  "version": "3.0.0",
  "hospital_location": [
    "Demo General Hospital"
  ],
  "hospital_address": [
    "1 Synthetic Way, Cheyenne, WY 82001"
  ],
  "license_information": {
    "license_number": "SYNTHETIC",
    "state": "WY"
  },
  "affirmation": {
    "affirmation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information is true, accurate, and complete.",
    "confirm_affirmation": true
  },
  "standard_charge_information": [
    {
      "description": "MRI brain w/o contrast",
      "code_information": [
        {
          "code": "70551",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100.0,
          "discounted_cash": 60.0,
          "minimum": 40.0,
          "maximum": 80.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 55.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 70.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 50.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "MRI brain w/ contrast",
      "code_information": [
        {
          "code": "70552",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200.0,
          "discounted_cash": 120.0,
          "minimum": 80.0,
          "maximum": 160.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 110.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 140.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 100.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "CT head w/o contrast",
      "code_information": [
        {
          "code": "70450",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 300.0,
          "discounted_cash": 180.0,
          "minimum": 120.0,
          "maximum": 240.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 165.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 210.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 150.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Chest X-ray, 2 views",
      "code_information": [
        {
          "code": "71046",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 400.0,
          "discounted_cash": 240.0,
          "minimum": 160.0,
          "maximum": 320.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 220.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 280.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 200.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Basic metabolic panel",
      "code_information": [
        {
          "code": "80048",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 500.0,
          "discounted_cash": 300.0,
          "minimum": 200.0,
          "maximum": 400.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 275.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 350.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 250.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Comprehensive metabolic panel",
      "code_information": [
        {
          "code": "80053",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 600.0,
          "discounted_cash": 360.0,
          "minimum": 240.0,
          "maximum": 480.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 330.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 420.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 300.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Complete blood count",
      "code_information": [
        {
          "code": "85025",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700.0,
          "discounted_cash": 420.0,
          "minimum": 280.0,
          "maximum": 560.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 385.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 490.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 350.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Lipid panel",
      "code_information": [
        {
          "code": "80061",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 800.0,
          "discounted_cash": 480.0,
          "minimum": 320.0,
          "maximum": 640.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 440.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 560.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 400.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Mammography screening",
      "code_information": [
        {
          "code": "77067",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 900.0,
          "discounted_cash": 540.0,
          "minimum": 360.0,
          "maximum": 720.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 495.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 630.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 450.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Ultrasound abdomen, complete",
      "code_information": [
        {
          "code": "76700",
          "type": "CPT"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1000.0,
          "discounted_cash": 600.0,
          "minimum": 400.0,
          "maximum": 800.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 550.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 700.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 500.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Synthetic implant, each",
      "code_information": [
        {
          "code": "C1713",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1100.0,
          "discounted_cash": 660.0,
          "minimum": 440.0,
          "maximum": 880.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 605.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 770.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 550.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    },
    {
      "description": "Injection, synthetic drug, per unit",
      "code_information": [
        {
          "code": "J1200",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1200.0,
          "discounted_cash": 720.0,
          "minimum": 480.0,
          "maximum": 960.0,
          "payers_information": [
            {
              "payer_name": "Demo Insurer",
              "plan_name": "PPO",
              "standard_charge_dollar": 660.0,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Demo Insurer",
              "plan_name": "HMO",
              "standard_charge_percentage": 70.0,
              "estimated_amount": 840.0,
              "methodology": "percent of total billed charges"
            },
            {
              "payer_name": "Demo Health",
              "plan_name": "Select",
              "standard_charge_dollar": 600.0,
              "algorithm": "lesser of billed charges or fee schedule"
            }
          ]
        }
      ]
    }
  ]
}