{ "hospital_name": "Mt. Grant General Hospital", "last_updated_on": "2025-09-10", "version": "2.0.0", "hospital_location": [ "Mt Grant General Hospital" ], "hospital_address": [ "200 S. A St., Hawthorne, NV 89415" ], "license_information": { "state": "NV", "license_number": "RVH-651" }, "affirmation": { "confirm_affirmation": true, "affirmation": "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated." }, "hospital_financial_aid_policy": "https://mgghnv.org/no-surprises-act/", "standard_charge_information": [ { "description": "HH ADSD HOMEMAKER 0.25 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3.75, "minimum": 3.75 } ] }, { "description": "HH ADSD HOMEMAKER 0.5 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 7.5, "minimum": 7.5 } ] }, { "description": "HH CHIPS HOMEMAKER 0.25 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3.75, "minimum": 3.75 } ] }, { "description": "HH ADSD HOMEMAKER 1 HOUR", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "HH CHIPS HOMEMAKER 0.5 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 7.5, "minimum": 7.5 } ] }, { "description": "HH ADSD ATTENDANT 0.25 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4.25, "minimum": 4.25 } ] }, { "description": "HH CHIPS HOMEMAKER 1 HOUR", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "HH ADSD ATTENDANT 0.5 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8.5, "minimum": 8.5 } ] }, { "description": "HH CHIPS ATTENDANT 0.25 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4.25, "minimum": 4.25 } ] }, { "description": "HH ADSD ATTENDANT 1 HOUR", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 17, "minimum": 17 } ] }, { "description": "HH CHIPS ATTENDANT 0.5 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8.5, "minimum": 8.5 } ] }, { "description": "HH CHIPS ATTENDANT 1 HOUR", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 17, "minimum": 17 } ] }, { "description": "RUBELLA ANTIBODIES (IGG, IGM)", "code_information": [ { "code": "86762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LACTATE DEHYDROGENASE (LD) ISOENZYME PANEL", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MICROALBUMIN, RANDOM URINE WITH CREATININE (6517)", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALPHA-THALASSEMIA DNA MUTATION ANALYSIS", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MISCELLANEOUS SENDOUT TEST", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ANCA VASCULITIDES", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TESTOSTERONE, FREE, BIOAVAILABLE AND TOTAL, LC/MS/MS", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "17-KETOSTEROIDS W/CREAT, 24-HR URINE", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "5-HYDROXYINDOLEACETIC ACID (5-HIAA), 24-HR URINE W/CREAT", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "5-HYDROXYINDOLEACETIC ACID (5-HIAA), RANDOM URINE", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "THYROID PANEL", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NO CHARGE", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLOTRIMAZOLE 10 MG TROCHE", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00054414622", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "WATER FOR INJECTION, STERILE INJECTION SOLUTION", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SULFASALAZINE 500 MG TABLET", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "00591079601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BICALUTAMIDE 50 MG TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "41616048583", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HH IIIB HOMEMAKER 0.25 HOURS", "code_information": [ { "code": "99600,LO", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4.42, "minimum": 4.42 } ] }, { "description": "HH IIIB HOMEMAKER 0.5 HOURS", "code_information": [ { "code": "99600,ME", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8.84, "minimum": 8.84 } ] }, { "description": "HH IIIB HOMEMAKER 1 HOUR", "code_information": [ { "code": "99600,HI", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 17.68, "minimum": 17.68 } ] }, { "description": "NO CHARGE VISIT", "code_information": [ { "code": "0526", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NURSE-ONLY VISIT, NO CHG", "code_information": [ { "code": "99211,NC", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "POSTOPERATIVE FOLLOW-UP VISIT, INCLUDED IN SURGICAL PACKAGE", "code_information": [ { "code": "99024", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CARRY GOAL STATUS", "code_information": [ { "code": "G8985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 0.01, "minimum": 0.01 } ] }, { "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK", "drug_information": { "unit": "100", "type": "ML" }, "code_information": [ { "code": "00338055318", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN E 200 UNIT CAPSULE", "drug_information": { "unit": "200", "type": "UN" }, "code_information": [ { "code": "00904027260", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NO SHOW FEE", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "SUPPLIES", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2, "minimum": 2 } ] }, { "description": "JAK2 EXONS 12 AND 13 MUTATIONS, QUALITATIVE, LEUMETA", "code_information": [ { "code": "81403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LIVER FIBROSIS PANEL", "code_information": [ { "code": "81596", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 430, "minimum": 430 } ] }, { "description": "PEDIATRIC ROOM", "code_information": [ { "code": "0123", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1618, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1618, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1618, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1584, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1483, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1703, "minimum": 1703 } ] }, { "description": "RECOVERY ROOM", "code_information": [ { "code": "0710", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "RECOVERY ROOM/HR (\u003e 1 HR)", "code_information": [ { "code": "0710", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "YAG LASER", "code_information": [ { "code": "66821,RT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 680, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 781, "minimum": 781 } ] }, { "description": "YAG LASER LT", "code_information": [ { "code": "66821,LT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 680, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 781, "minimum": 781 } ] }, { "description": "CASTING ROLL FIBERGLASS", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "FLEX A FLOW FEED TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "URINARY LEG BAG", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "COBAN 3 IN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "ELASTAPLAST", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "COBAN 6 IN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "BANDAGE CONFORM GAUZE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "BANDAGE ACE WRAP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "EXTERNAL PACING", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 396, "minimum": 396 } ] }, { "description": "GELOCAST UNNA BOOT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "COBAN STERILE 6 IN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 35, "minimum": 35 } ] }, { "description": "FEMALE MINI CATH KIT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "CATHETER MALE TEXAS", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 35, "minimum": 35 } ] }, { "description": "CATHETER FOLEY TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 46, "minimum": 46 } ] }, { "description": "CATHETER SUBCLAVIAN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 66, "minimum": 66 } ] }, { "description": "SUCTION TIP CATHETER 18FR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "CATHETER SUPRAPUBIC", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 228, "minimum": 228 } ] }, { "description": "CATHETER UMBILICAL VESSEL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "URINARY DRAINAGE BAG", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "JACKSON PRATT DRAIN OR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "JACKSON PRATT RESERVOIR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "PENROSE DRAIN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "DRSG COMBINE ABD 8X10", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 24, "minimum": 24 } ] }, { "description": "DUODERM 4X4", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "DUODERM 8X8", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 29, "minimum": 29 } ] }, { "description": "BANDAGE GAUZE BULKY", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "DRSG NONADHERING", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "DRSG TRANSPARENT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "DRSG, INTRASITE GEL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 19, "minimum": 19 } ] }, { "description": "PACKING OXCEL 2IN BOTTLE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "DRSG, ADHESIVE SURG 8X6", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "DRSG VASELINE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "VENA GUARD", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "DRSG XEROFORM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 18, "minimum": 18 } ] }, { "description": "CURAD ENEMA 19 GRAM-7 GRAM/118 ML", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 24, "minimum": 24 } ] }, { "description": "SOAP SUDS ENEMA", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "K-PAD DISPOSABLE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "PLEURAVAC", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 811, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 760, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 872, "minimum": 872 } ] }, { "description": "AQUACEL DRESS", "code_information": [ { "code": "A6223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 367, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 395, "minimum": 395 } ] }, { "description": "PACKING VASELINE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "DRSG XEROFORM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 18, "minimum": 18 } ] }, { "description": "PACKING NUGAUZE IODOFORM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "PACKING NUGAUZE PLAIN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "MITEK MINI ANCHOR", "code_information": [ { "code": "99070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "HEPARIN LOCK", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 34, "minimum": 34 } ] }, { "description": "EPISTAXI PACKING", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "ELBOW TURN BUCKLE ORTHOSI", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 329, "minimum": 329 } ] }, { "description": "IV CATHETER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 34, "minimum": 34 } ] }, { "description": "SPLINT, FINGER W/CLOSURE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 40, "minimum": 40 } ] }, { "description": "SPLINT, ANKLE AIR STIRUP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "SPLINT, ARM IMMOBILIZER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "INTRAOSSEOUS NEEDLE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 394, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 394, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 394, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 415, "minimum": 415 } ] }, { "description": "RIB BELT WOMAN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 65, "minimum": 65 } ] }, { "description": "RIB BELT MEN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 65, "minimum": 65 } ] }, { "description": "FOAM WALKER BOOT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 238, "minimum": 238 } ] }, { "description": "SPLINT, ANKLE CANVAS BRAC", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "SPLINT, BACK BRACE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "CAST ARM FULL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 205, "minimum": 205 } ] }, { "description": "CAST HAND", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 103, "minimum": 103 } ] }, { "description": "CAST FOREARM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "CAST LEG FULL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 222, "minimum": 222 } ] }, { "description": "CAST LEG HALF", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "CAST POSTERIOR ARM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 103, "minimum": 103 } ] }, { "description": "CAST POSTERIOR LEG", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 103, "minimum": 103 } ] }, { "description": "SPLINT, PLASTER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "SPLINT, CLAVICLE BRACE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "CATHETER SELF TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "CERVICAL COLLAR PHILADEL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 113, "minimum": 113 } ] }, { "description": "CERVICAL STIFFNECK COLLAR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "SPLINT, MULTI KNEE PANEL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 176, "minimum": 176 } ] }, { "description": "SPLINT KNEE SUPPORT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 163, "minimum": 163 } ] }, { "description": "CAST SHOE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "ARM SLING", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "POLYPECTOMY SNARE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "SPLINT, FINGER STRIP 2\"", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "SPLINT, BASEBALL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 17, "minimum": 17 } ] }, { "description": "SPLINT,MASON ALLEN COCKUP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 65, "minimum": 65 } ] }, { "description": "SPLINT,FOREARM PADDED", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "SPLINT THUMB SPICA", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "SPLINT, ELASTIC WRIST", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "SPLINT, FOAM WRIST", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "TENNIS ELBOW SUPPORT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 16, "minimum": 16 } ] }, { "description": "INTRAOCULAR LENS", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 284, "minimum": 284 } ] }, { "description": "ALCON TORIC LENS", "code_information": [ { "code": "V2787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 945, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 945, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 945, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 925, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 867, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 995, "minimum": 995 } ] }, { "description": "SOFTWICK DRAIN SPONGE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 9, "minimum": 9 } ] }, { "description": "DRSG, GAUZE STERILE 4X4", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "TED STOCKING ALL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 64, "minimum": 64 } ] }, { "description": "ABDOMINAL BINDER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 133, "minimum": 133 } ] }, { "description": "CATHETER LEG STRAP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 35, "minimum": 35 } ] }, { "description": "SUCTION CANISTER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 35, "minimum": 35 } ] }, { "description": "FEMALE MINI CATH KIT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "PACKING SURGICEL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "BILATERAL NASAL PAC", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 74, "minimum": 74 } ] }, { "description": "SUTURE EACH", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "STAPLE REMOVER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "STAPLER 5 SHOT OR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "BALLOON DILATOR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "NASAL PAC", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "STERI STRIP PACK ONE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "INFLATION DILATION", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "COLONIC OVERTUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "MASTASOL 1 APPLICATION", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 7, "minimum": 7 } ] }, { "description": "TRAY FOLEY", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "HAND/WRIST/FINGR ORTHOSIS", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 280, "minimum": 280 } ] }, { "description": "TRAY IRRIGATION", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 44, "minimum": 44 } ] }, { "description": "BIOFLEX PLA PIN", "code_information": [ { "code": "A4649", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 524, "minimum": 524 } ] }, { "description": "SURGICAL STEEL SUTURE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 40, "minimum": 40 } ] }, { "description": "K-WIRE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "TRAY URETHRAL CATH", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "TRACHEOTOMY CARE KIT", "code_information": [ { "code": "A4629", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "TRIPLE LUMEN CATH KIT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 107, "minimum": 107 } ] }, { "description": "IRRIGATION TUBE 4 LEAD", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 113, "minimum": 113 } ] }, { "description": "CATHETER,URETHRAL RED RUB", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 16, "minimum": 16 } ] }, { "description": "INTERJECT INJECTION NEEDL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "FEEDING TUBE ALL SIZE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "OSTMY SKIN BARR FILM EACH", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4, "minimum": 4 } ] }, { "description": "HEASINE PASTE 1OZ", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "LEG BAG ADAPTER \u0026 TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "SALEM SUMP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "PUPIL DILATOR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "URIMETER DRAIN BAG", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "COLOSTOMY WAFER EA", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "COLOSTOMY BAGS EA", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 7, "minimum": 7 } ] }, { "description": "RESOLUTION CLIP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "PROMOGRAN DRESSING", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "COLLAGEN MATRIX 5CM X 2CM", "code_information": [ { "code": "A6024", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1133, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1061, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1218, "minimum": 1218 } ] }, { "description": "CALCIUM ALGINATE DRESSING 2X2", "code_information": [ { "code": "A6196", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6, "minimum": 6 } ] }, { "description": "ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND, FILLER, STERILE, PER 6 IN", "code_information": [ { "code": "A6199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "ROTH NET STANDARD", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "POLY TRAP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "VAC GRANUFOAM SM DRSG", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 64, "minimum": 64 } ] }, { "description": "ATS CANISTER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "ROTH NET, FOOD BOLUS RTRV", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "6 SHOT MULTI BAND LIGATOR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 571, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 535, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 614, "minimum": 614 } ] }, { "description": "SPRAY CATHETER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "ALLEVYN CLASSIC WOUND DRSG 3\" x 3\"", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 14, "minimum": 14 } ] }, { "description": "ALLEVYN CLASSIC WOUND DRSG 5\" x 5\"", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "RESTORE SILVER ALGINATE 4\" x 4.75\"", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "BALLOON 8, 9, 10 MM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "DERMABOND, TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 101, "minimum": 101 } ] }, { "description": "TRACHEOSTOMY TUBE DISPOSA", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "TRACHEAL INNER CANNULA", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "LIGATOR BAND, HEMORRHOID", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "ORTHOPEDIC SCREW", "code_information": [ { "code": "A4649", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 400, "minimum": 400 } ] }, { "description": "ESOPHAG COLON BALLOON DIL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 592, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 637, "minimum": 637 } ] }, { "description": "OCULAR IMPLANT", "code_information": [ { "code": "L8610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "PEG TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 440, "minimum": 440 } ] }, { "description": "VAC ATS THER UNIT PER DAY", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "REPLACEMENT PEG TUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 74, "minimum": 74 } ] }, { "description": "RHYTHM STRIP", "code_information": [ { "code": "93005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "UPPER EXTREMITY LT WO/W CONTR", "code_information": [ { "code": "73202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2092, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1959, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2249, "minimum": 2249 } ] }, { "description": "ARTERIAL KIT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "BAG AMBU DISPOSABLE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "CANNULA PEDIATRIC/INFANT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "AIRWAY ORAL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "EASY CAP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "TUBE ENDO TRACHEAL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 123, "minimum": 123 } ] }, { "description": "KING TUBE", "code_information": [ { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "TUBE HOLDER ENDO TRACHEAL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 43, "minimum": 43 } ] }, { "description": "HUMIDIFIER DISPOSABLE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 40, "minimum": 40 } ] }, { "description": "OXYGEN TUBING CONNECTOR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 10, "minimum": 10 } ] }, { "description": "LUNG VOLUME EXERCISER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 72, "minimum": 72 } ] }, { "description": "MASK AEROSOL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "MASK HIGH CONCENTRATION", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "MASK NON-REBREATHING", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "MASK SIMPLE OXYGEN ADULT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "MASK TRACHEAL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "MASK VENTI", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 29, "minimum": 29 } ] }, { "description": "MDI SPACER W/WO MASK", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "MASK SIMPLE OXY, PED/INF", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 24, "minimum": 24 } ] }, { "description": "MIST TENT CANOPY", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 130, "minimum": 130 } ] }, { "description": "MIST TENT PER HR W/O O2", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "MIST TENT PER HR WITH O2", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 43, "minimum": 43 } ] }, { "description": "MUCUS DELEE TRAP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "NASO/PHARY AIRWAY", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "NEBULIZER PACKAGE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "OXISENSOR", "code_information": [ { "code": "0410", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "OXYGEN CANNULA ADULT", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "TUBING OXYGEN 21 FEET", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "PEAK FLOW METER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "TUBING LARGE BORE 3 FEET", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 24, "minimum": 24 } ] }, { "description": "WATER TRAP", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "FLUTTER VALVE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "Variable concentration mask", "code_information": [ { "code": "A4620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 14, "minimum": 14 } ] }, { "description": "COMBITUBE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 222, "minimum": 222 } ] }, { "description": "SMART VEST - VEST ONLY", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 295, "minimum": 295 } ] }, { "description": "Phosphorus, 24-hr urine", "code_information": [ { "code": "84105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "RENAL PANEL", "code_information": [ { "code": "80069", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "ETOH", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 176, "minimum": 176 } ] }, { "description": "DIRECT COOMBS", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "BLEEDING TIME", "code_information": [ { "code": "85002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 113, "minimum": 113 } ] }, { "description": "CHLORIDE", "code_information": [ { "code": "82436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 21, "minimum": 21 } ] }, { "description": "CARBON DIOXIDE", "code_information": [ { "code": "82374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "GENERAL HEALTH PANEL", "code_information": [ { "code": "80050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 349, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 375, "minimum": 375 } ] }, { "description": "LIVER PANEL", "code_information": [ { "code": "80076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 133, "minimum": 133 } ] }, { "description": "DRUGS OF ABUSE SCREEN (DAU)", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "ERRG - DRUGS OF ABUSE SCREEN (DAU)", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 121, "minimum": 121 } ] }, { "description": "WHITE BLOOD COUNT", "code_information": [ { "code": "85048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "RED BLOOD CELLS COUNT", "code_information": [ { "code": "85041", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "LITHIUM", "code_information": [ { "code": "80178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "OCCULT BLOOD", "code_information": [ { "code": "82270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "IPPB TX INITIAL", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 72, "minimum": 72 } ] }, { "description": "PEAK FLOW RATE", "code_information": [ { "code": "94060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 43, "minimum": 43 } ] }, { "description": "PROTIME W/INR", "code_information": [ { "code": "85610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "SODIUM", "code_information": [ { "code": "84295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "HDL CHOLESTEROL", "code_information": [ { "code": "83718", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "BUN", "code_information": [ { "code": "84520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "Manual Diff", "code_information": [ { "code": "85007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "TOTAL PROTEIN", "code_information": [ { "code": "84157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "30 min post lactose dose", "code_information": [ { "code": "82951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "60 min post lactose dose", "code_information": [ { "code": "82951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "90 min post lactose dose", "code_information": [ { "code": "82951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "120 min post lactose dose", "code_information": [ { "code": "82952", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "180 min post lactose dose", "code_information": [ { "code": "82952", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "210 min post lactose dose", "code_information": [ { "code": "82952", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "ALBUTEROL, SERUM/PLASMA", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 322, "minimum": 322 } ] }, { "description": "XR--ACROMIOCLAVICULAR JOINT.BILATERAL--VIEWS^W \u0026 WO WEIGHT", "code_information": [ { "code": "73050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "ACETONE", "code_information": [ { "code": "82010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 189, "minimum": 189 } ] }, { "description": "XR--ANKLE.RIGHT--VIEWS 2", "code_information": [ { "code": "73600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "ANTIMONY, BLOOD", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "XR--UPPER EXTREMITY.RIGHT--VIEWS (INFANT)", "code_information": [ { "code": "73092", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 204, "minimum": 204 } ] }, { "description": "XR--GASTROINTESTINAL SYSTEM+RESPIRATORY SYSTEM--VIEW FOR FOREIGN BODY", "code_information": [ { "code": "76010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 216, "minimum": 216 } ] }, { "description": "HIV 1/2 AG,AB W/RX,4GEN", "code_information": [ { "code": "87389", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "MUMPS VIRUS ANTIBODY (IGM)", "code_information": [ { "code": "86735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 237, "minimum": 237 } ] }, { "description": "SOMATOSTATIN", "code_information": [ { "code": "84307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "HEREDITARY HEMOCHROMATOSIS DNA MUTATION ANALYSIS", "code_information": [ { "code": "81256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 733, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 686, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 788, "minimum": 788 } ] }, { "description": "Fibroblast Growth Factor 23, Quant, Plasma", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 349, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 375, "minimum": 375 } ] }, { "description": "HAND - BILATERAL X-RAY ARTHRITIS", "code_information": [ { "code": "73120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 216, "minimum": 216 } ] }, { "description": "CORTISOL, FREE, 24-HR URINE W/CREAT", "code_information": [ { "code": "82530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "Free Cortisol", "code_information": [ { "code": "82530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "CALCIUM, 24-HR URINE W/O CREAT", "code_information": [ { "code": "82340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "XR--SPINE.LUMBAR--VIEW 1", "code_information": [ { "code": "72020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 207, "minimum": 207 } ] }, { "description": "HEPATITIS BE ANTIGEN", "code_information": [ { "code": "87350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "5-HYDROXYINDOLEACETIC ACID (5-HIAA), 24-HR URINE", "code_information": [ { "code": "83497", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "5 \u0027NUCLEOTIDASE", "code_information": [ { "code": "83915", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "ALDOSTERONE, SERUM", "code_information": [ { "code": "82088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 354, "minimum": 354 } ] }, { "description": "HIV-1 RNA, QUANTITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 812, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 812, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 812, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 795, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 745, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 855, "minimum": 855 } ] }, { "description": "ANGIOTENSIN CONVERTING ENZYME (ACE) POLYMORPHISM (INSERTION/DELETION)", "code_information": [ { "code": "81400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "ACETONE, SEMI-QUANTITATIVE", "code_information": [ { "code": "82009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 764, "minimum": 764 } ] }, { "description": "XR--CHEST--VIEW AP LATERAL-DECUBITUS", "code_information": [ { "code": "71048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "XR--CHEST--VIEWS 4", "code_information": [ { "code": "71048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 369, "minimum": 369 } ] }, { "description": "XR--ELBOW.LEFT--VIEWS 3", "code_information": [ { "code": "73080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 250, "minimum": 250 } ] }, { "description": "XR--ESOPHAGUS--VIEWS^W CONTRAST PO", "code_information": [ { "code": "74220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 437, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 437, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 437, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 460, "minimum": 460 } ] }, { "description": "XR--ORBIT.BILATERAL--VIEWS FOR FOREIGN BODY", "code_information": [ { "code": "70030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "XR--FACIAL BONES--VIEWS 1 OR 2", "code_information": [ { "code": "70140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 294, "minimum": 294 } ] }, { "description": "XR--FEMUR.RIGHT--VIEWS", "code_information": [ { "code": "73552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 321, "minimum": 321 } ] }, { "description": "XR--FOOT.RIGHT--VIEWS 2", "code_information": [ { "code": "73620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "FOOT - BILATERAL X-RAY AP SINGLE VIEW", "code_information": [ { "code": "0320", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "XR--HAND.RIGHT--VIEWS 2", "code_information": [ { "code": "73120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "XR--KNEE.BILATERAL--VIEWS \u0026 (VIEW AP^STANDING)", "code_information": [ { "code": "73565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 272, "minimum": 272 } ] }, { "description": "KNEE - BILATERAL X-RAY 2 VIEWS STANDING", "code_information": [ { "code": "73565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "XR--MANDIBLE--VIEWS LIMITED", "code_information": [ { "code": "70100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 342, "minimum": 342 } ] }, { "description": "XR--MASTOID.RIGHT--VIEWS 3", "code_information": [ { "code": "70130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 584, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 584, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 584, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 572, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 615, "minimum": 615 } ] }, { "description": "XR--OPTIC FORAMEN.BILATERAL--VIEWS", "code_information": [ { "code": "70190", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 305, "minimum": 305 } ] }, { "description": "XR--ORBIT.BILATERAL--VIEWS 4", "code_information": [ { "code": "70200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 390, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 390, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 390, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 382, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 411, "minimum": 411 } ] }, { "description": "XR--PELVIS--VIEWS 3", "code_information": [ { "code": "72190", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 342, "minimum": 342 } ] }, { "description": "SC JOINTS MIN 3 VIEWS (STERNAL CLAVICULAR)", "code_information": [ { "code": "71130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 311, "minimum": 311 } ] }, { "description": "XR--SELLA TURCICA--VIEWS", "code_information": [ { "code": "70240", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 259, "minimum": 259 } ] }, { "description": "XR--SINUSES--VIEWS 1 OR 2", "code_information": [ { "code": "70210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 321, "minimum": 321 } ] }, { "description": "XR--SKULL--VIEWS 4", "code_information": [ { "code": "70260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 378, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 434, "minimum": 434 } ] }, { "description": "XR--ABDOMEN--VIEWS (SITZMARK)", "code_information": [ { "code": "74250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 579, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 579, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 579, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 566, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 530, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 609, "minimum": 609 } ] }, { "description": "XR--TIBIA.RIGHT+FIBULA.RIGHT--VIEWS 2", "code_information": [ { "code": "73590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "XR--GREAT TOE.LEFT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 237, "minimum": 237 } ] }, { "description": "XR--TOE.THIRD.LEFT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "XR--TOE.FOURTH.LEFT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "XR--TOE.FIFTH.LEFT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "XR--GREAT TOE.RIGHT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 237, "minimum": 237 } ] }, { "description": "XR--TOE.THIRD.RIGHT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "XR--TOE.FOURTH.RIGHT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "XR--TOE.FIFTH.RIGHT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "XR--WRIST.RIGHT--VIEWS 2", "code_information": [ { "code": "73100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "XR--LOWER EXTREMITY.RIGHT--VIEWS", "code_information": [ { "code": "73592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 204, "minimum": 204 } ] }, { "description": "XR--ANKLE.LEFT--VIEWS 2", "code_information": [ { "code": "73600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "XR--UPPER EXTREMITY.LEFT--VIEWS (INFANT)", "code_information": [ { "code": "73092", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 204, "minimum": 204 } ] }, { "description": "XR--ELBOW.RIGHT--VIEWS 3", "code_information": [ { "code": "73080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 250, "minimum": 250 } ] }, { "description": "XR--FOOT.LEFT--VIEWS 2", "code_information": [ { "code": "73620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "XR--HAND.LEFT--VIEWS 2", "code_information": [ { "code": "73120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "XR--HIP.LEFT--VIEW 1", "code_information": [ { "code": "73501", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 248, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 267, "minimum": 267 } ] }, { "description": "XR--TIBIA.LEFT+FIBULA.LEFT--VIEWS 2", "code_information": [ { "code": "73590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "XR--WRIST.LEFT--VIEWS 2", "code_information": [ { "code": "73100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "CT CHEST/ABDOMEN WITH IV CONTRAST", "code_information": [ { "code": "0350", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4069, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4069, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4069, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3983, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3730, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1499, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1499, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1499, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1499, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1499, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4283, "minimum": 4283 } ] }, { "description": "CT CHEST/ABDOMEN W/O IV CONTRAST", "code_information": [ { "code": "0350", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3052, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3052, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3052, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2988, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2799, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3213, "minimum": 3213 } ] }, { "description": "SINUSES LIMITED OR FOLLOW UP CT", "code_information": [ { "code": "76380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 600, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 600, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 600, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 588, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 632, "minimum": 632 } ] }, { "description": "CT--SINUSES--MULTISECTION CORONAL SAGITTAL", "code_information": [ { "code": "70486,TC", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2046, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2046, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2046, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2003, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1876, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2154, "minimum": 2154 } ] }, { "description": "ORBIT WO/W CONTRAST", "code_information": [ { "code": "70482", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2057, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2057, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2057, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2013, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1886, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2165, "minimum": 2165 } ] }, { "description": "UPPER EXTREMITY RT WO/W CONTR", "code_information": [ { "code": "73202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2092, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1959, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2249, "minimum": 2249 } ] }, { "description": "BONE DENSITY SPINE / HIP", "code_information": [ { "code": "77078,TC", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 451, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 485, "minimum": 485 } ] }, { "description": "IV CONTRAST UP TO 50CC", "code_information": [ { "code": "Q9967,LO", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "IV CONTRAST UP TO 150CC", "code_information": [ { "code": "Q9967,HI", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 318, "minimum": 318 } ] }, { "description": "CT ABD PELVIS W / O CONTRAST", "code_information": [ { "code": "74176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3096, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2900, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3329, "minimum": 3329 } ] }, { "description": "CT--ABDOMEN PELVIS IV AND ORAL WITH CONTRAST", "code_information": [ { "code": "74177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4092, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3832, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4400, "minimum": 4400 } ] }, { "description": "CT--ABDOMEN PELVIS IV ONLY", "code_information": [ { "code": "74177,TC", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4092, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3832, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4400, "minimum": 4400 } ] }, { "description": "CT ANGIO-RENAL VESSALS-W AND WO CONTRAST", "code_information": [ { "code": "75733", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1926, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1926, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1926, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1885, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1766, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2027, "minimum": 2027 } ] }, { "description": "CTA RT LEG W/IV", "code_information": [ { "code": "73706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2234, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2092, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 841, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 841, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 841, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 841, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 841, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2402, "minimum": 2402 } ] }, { "description": "CTA BILAT LEG W/IV", "code_information": [ { "code": "73706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3338, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3589, "minimum": 3589 } ] }, { "description": "MRI CHEST WO", "code_information": [ { "code": "71550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2103, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 845, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 845, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 845, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 845, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 845, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2415, "minimum": 2415 } ] }, { "description": "MRI CHEST WO/W", "code_information": [ { "code": "71552,TC", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2930, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2744, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3150, "minimum": 3150 } ] }, { "description": "MRI CHEST W", "code_information": [ { "code": "71552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2930, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2744, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3150, "minimum": 3150 } ] }, { "description": "UE LT NON JNT WO/W CONTR", "code_information": [ { "code": "73220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2376, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2225, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2555, "minimum": 2555 } ] }, { "description": "LIVER ULTRA SOUND", "code_information": [ { "code": "76705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 499, "minimum": 499 } ] }, { "description": "RETROPERITONEAL (EG, RENAL, AORTA, NODES) US LIMITED", "code_information": [ { "code": "76775", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 544, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 544, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 544, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 499, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 573, "minimum": 573 } ] }, { "description": "DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONINUOUS WAVE W/ SPECTRAL DISPLAY: COMPLETE", "code_information": [ { "code": "93320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 818, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 818, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 818, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 801, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 750, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 861, "minimum": 861 } ] }, { "description": "DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE W/ SPECTRAL DISPLAY: FOLLOW-UP OR LIMITED STUDY", "code_information": [ { "code": "93321", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 757, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 814, "minimum": 814 } ] }, { "description": "DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING", "code_information": [ { "code": "93325", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 695, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 798, "minimum": 798 } ] }, { "description": "U/S GUIDANCE NEEDL BIOPSY", "code_information": [ { "code": "76942", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 482, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 482, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 482, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 472, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 507, "minimum": 507 } ] }, { "description": "BREAST LT ULTRA SOUND", "code_information": [ { "code": "77061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "UNLISTED THERAPY PROC", "code_information": [ { "code": "97139", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "PHYS PERFORM TEST EVAL", "code_information": [ { "code": "97750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "PROSTHETIC TRAIN EA 15", "code_information": [ { "code": "97761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "WHIRLPOOL", "code_information": [ { "code": "97022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 61, "minimum": 61 } ] }, { "description": "MYOFASCIAL/SOFT TISSUE", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "ORTHOTICS FIT/TRAIN 15", "code_information": [ { "code": "97760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "UNLISTED THERAPY PROCEDUR", "code_information": [ { "code": "97139", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 61, "minimum": 61 } ] }, { "description": "UNLISTED MODALITY", "code_information": [ { "code": "97039", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 61, "minimum": 61 } ] }, { "description": "TAPING PROCEDURE", "code_information": [ { "code": "97799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 68, "minimum": 68 } ] }, { "description": "ELECTRODES SET OF 4", "code_information": [ { "code": "97799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "IONTO ELECTRODES", "code_information": [ { "code": "97799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "BRACE MOD/UNLST REHAB", "code_information": [ { "code": "97799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "ROM MEAS.\u0026 RPT EACH EXTRE", "code_information": [ { "code": "95851", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "CANALITH REPOSITIONING", "code_information": [ { "code": "95992", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "P/T EVAL MOD COMPLEX 30 MINS", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 303, "minimum": 303 } ] }, { "description": "P/T EVAL HIGH COMPLEX 45 MINS", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 364, "minimum": 364 } ] }, { "description": "ASSIST TECH ASSESS-1 ON 1", "code_information": [ { "code": "97755", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "IV THER CONCUR INFUS", "code_information": [ { "code": "96368", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "MNT; REASSESSMENT \u0026 SUBS INTERVENTION; MNT SUBS TREATMENT CHANGE IN DIAG; EACH 15 MIN", "code_information": [ { "code": "G0270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "MNT; REASSESSMENT \u0026 SUBS INTERVENTION; GROUP MNT 2 OR MORE; EACH 30 MIN", "code_information": [ { "code": "G0271", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "DRESSING CHANGE SIMPLE", "code_information": [ { "code": "99211,DC", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "BLADDER CATH NON INDWELL", "code_information": [ { "code": "51701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "TREATMENT ROOM PER HR", "code_information": [ { "code": "99211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "TREATMENT ROOM, MINIMAL", "code_information": [ { "code": "99211,TR", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "OP TREATMENT/SHORT STAY", "code_information": [ { "code": "99211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "INJ FEE ALLERGY (X1)", "code_information": [ { "code": "95115", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "INJ FEE ALLERGY (X2)", "code_information": [ { "code": "95117", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 43, "minimum": 43 } ] }, { "description": "COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE VENOUS ACCESS DEVICE", "code_information": [ { "code": "36591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "WHIRLPOOL BATH - OUTPATIENT NURSING SERVICES", "code_information": [ { "code": "97022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "IV THER CONCUR INFUS", "code_information": [ { "code": "96368", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "MNT; GROUP, 2 OR MORE, EACH 30 MIN", "code_information": [ { "code": "97804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 29, "minimum": 29 } ] }, { "description": "FETAL NON-STRESS", "code_information": [ { "code": "59025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "PSYCHIATRIC DIAGNOSTIC EVALUATION", "code_information": [ { "code": "90791", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "45 MIN PSYCHOTHERAPY", "code_information": [ { "code": "90836", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "PSY CONSULT 1 - ER", "code_information": [ { "code": "99281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "PSY CONSULT 2 - ER", "code_information": [ { "code": "99282", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 162, "minimum": 162 } ] }, { "description": "PSY CONSULT 3 - ER", "code_information": [ { "code": "99283", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "PSY CONSULT 4 - ER", "code_information": [ { "code": "99284", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 324, "minimum": 324 } ] }, { "description": "PSY CONSULT 5 - ER", "code_information": [ { "code": "99285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 394, "minimum": 394 } ] }, { "description": "PSY CONSULT 1 - IP", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "PSY CONSULT 2 - IP", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 133, "minimum": 133 } ] }, { "description": "PSY CONSULT 3 - IP", "code_information": [ { "code": "99221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "PSY CONSULT 4 - IP", "code_information": [ { "code": "99222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "PSY CONSULT 5 - IP", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 353, "minimum": 353 } ] }, { "description": "SPEECH DYSPHAGIA TX-15MIN", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "AUDIOMETRY EVAL", "code_information": [ { "code": "92557", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 204, "minimum": 204 } ] }, { "description": "HEARING AID CHK, MONAURAL", "code_information": [ { "code": "92592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 108, "minimum": 108 } ] }, { "description": "STD COGNITIVE PERFOR TEST", "code_information": [ { "code": "96125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "COMPLEX CATARACT SURG LT", "code_information": [ { "code": "66982,LT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4167, "minimum": 4167 } ] }, { "description": "TRABECULOPLASTY", "code_information": [ { "code": "65855", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 597, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 559, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 642, "minimum": 642 } ] }, { "description": "INTRACAP CATARACT REMV LT", "code_information": [ { "code": "66983,LT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3553, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3820, "minimum": 3820 } ] }, { "description": "EXTRACAP CATARACT REMV LT", "code_information": [ { "code": "66984,LT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4167, "minimum": 4167 } ] }, { "description": "LASER PERIPH IRIDOTOMY LT", "code_information": [ { "code": "66761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 597, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 559, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 642, "minimum": 642 } ] }, { "description": "LASER PERIPH IRIDOTOMY RT", "code_information": [ { "code": "66761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 597, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 559, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 642, "minimum": 642 } ] }, { "description": "DEST LES LID MARGN TO 1CM", "code_information": [ { "code": "67850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "COMPLEX CATARACT SURG RT", "code_information": [ { "code": "66982,RT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4167, "minimum": 4167 } ] }, { "description": "INTRACAP CATARACT REMV RT", "code_information": [ { "code": "66983,RT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3553, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1337, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3820, "minimum": 3820 } ] }, { "description": "EXTRACAP CATARACT REMV RT", "code_information": [ { "code": "66984,RT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3959, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3629, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4167, "minimum": 4167 } ] }, { "description": "IRIDECTOMY", "code_information": [ { "code": "66985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2090, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2090, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2090, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2046, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1916, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2200, "minimum": 2200 } ] }, { "description": "ANESTHESIA IV SED PER MIN", "code_information": [ { "code": "0370", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 9, "minimum": 9 } ] }, { "description": "ANESTHESIA CRNA PER UNIT", "code_information": [ { "code": "0370", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "OFFICE CONSULT L3 EST", "code_information": [ { "code": "99213,CS", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "OFFICE CONSULT L5 EST", "code_information": [ { "code": "99215,CS", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 528, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 495, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 568, "minimum": 568 } ] }, { "description": "PEG TUBE REMOVAL", "code_information": [ { "code": "43500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "EST OFF VST-STRAIGHT FWD", "code_information": [ { "code": "99212,OF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "OFFICE CONSULT L2 NEW", "code_information": [ { "code": "99202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "OFFICE CONSULT L3 NEW", "code_information": [ { "code": "99203", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 382, "minimum": 382 } ] }, { "description": "OFFICE CONSULT L4 NEW", "code_information": [ { "code": "99204", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 443, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 509, "minimum": 509 } ] }, { "description": "OFFICE CONSULT L5 NEW", "code_information": [ { "code": "99205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 592, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 637, "minimum": 637 } ] }, { "description": "ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "50383007916", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MAPAP (ACETAMINOPHEN) 325 MG TABLET", "drug_information": { "unit": "325", "type": "UN" }, "code_information": [ { "code": "63739044001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MAPAP EXTRA STRENGTH 500 MG TABLET", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "00904198880", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACETAZOLAMIDE 500 MG/VIAL, J1120 - INJECTION, UP TO 500 MG", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "25021081710", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACYCLOVIR 200 MG CAPSULE", "drug_information": { "unit": "200", "type": "UN" }, "code_information": [ { "code": "00093894001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ADENOSINE 6 MG/SYR (3 MG/ML), J0153 - INJECTION, PER 1 MG", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00469823412", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHILD PAIN-FEVER 160 MG/5 ML 5 mL, 118 mL", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "50580042401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACIDOPHILUS CAPLET 1 ea, 100 eaches", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00536718001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN C 500 MG TABLET 500 mg, 100 eaches", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "00904052361", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "atorvastatin 20 MG TABLET 20 ea, 100 eaches", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00904629161", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "carvedilol 12.5 MG TABLET 12.5 ea, 100 eaches", "drug_information": { "unit": "12.5", "type": "UN" }, "code_information": [ { "code": "00904630261", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXTROSE 25%-WATER SYRINGE 1 ea, 10 mL", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00409177510", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DOPamine 800 MG-D5W 250 ML 40 mg, 250 mL", "drug_information": { "unit": "40", "type": "GR" }, "code_information": [ { "code": "00409781022", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALBUTEROL SULFATE 2 MG/5 ML SYRUP", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "00093066116", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DOXYCYCLINE MONO 100 MG CAP 100 mg, 20 eaches", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "68084074332", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ENOXAPARIN 60 MG/0.6 ML SYR 1 mg, 0.6 mL", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "63323056888", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ENOXAPARIN 80 MG/0.8 ML SYR 1 mg, 0.8 mL", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "63323056890", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INTEGRILIN 20 MG/10 ML VIAL 5 mg, 10 mL", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00085117705", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SM TUSSIN DM LIQUID 5 mL, 237 mL", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "49348086137", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HYDROCORTISONE AC 25 MG SUPP 25 mg, 12 eaches", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "42494030112", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALBUTEROL SULFATE ER 4 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "unit": "4", "type": "UN" }, "code_information": [ { "code": "00378412201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "metoprolol succ ER 50 MG TAB 50 ea, 100 eaches", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "68084066601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALLOPURINOL 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "00603211521", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "morphine SULFATE 5 MG/ML VIAL 10 mg, 1 mL", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "63323045501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMIODARONE 450 MG/9 ML, J0282 - INJECTION, PER 30 MG", "drug_information": { "unit": "30", "type": "GR" }, "code_information": [ { "code": "63323061609", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALTEPLASE 100 MG/VIAL, J2997 - INJECTION, PER 1 MG", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "50242008527", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMPICILLIN/SULBACTAM 3G/VIAL, J0295 - INJECTION, PER 1.5 GM", "drug_information": { "unit": "1.5", "type": "GR" }, "code_information": [ { "code": "63323036920", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMITRIPTYLINE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "00378262501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMLODIPINE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "63739063110", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00093227434", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMOXICILLIN 250 MG CAPSULE", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "00781202001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "66685100101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMPICILLIN 1000 MG/VIAL, J0290 - INJECTION, PER 500 MG", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "63323038910", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ASPIRIN 81 MG TABLET,DELAYED RELEASE", "drug_information": { "unit": "81", "type": "UN" }, "code_information": [ { "code": "00603002622", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ASPIRIN 325 MG TABLET", "drug_information": { "unit": "325", "type": "UN" }, "code_information": [ { "code": "57896090101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ATENOLOL 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "51079075920", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BACLOFEN 20 MG TABLET", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00172409760", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BENZTROPINE 1 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00832108100", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BETHANECHOL CHLORIDE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "00832051100", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLARITHROMYCIN 250 MG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "00527193106", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFUROXIME AXETIL 250 MG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "64679092101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BISAC-EVAC 10 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "00713010901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFTAZIDIME 1 GM/VIAL, J0713 - INJECTION, PER 500 MG", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00781317796", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CIPROFLOXACIN 250 MG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "68084006901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BUMETANIDE 1 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00093423301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00591336901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BUTORPHANOL 2 MG/ML (1ML), J0595 - INJECTION, PER 1 MG", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00409162601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "76329330401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DENOSUMAB 1 MG INJ", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "55513073001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CARBAMAZEPINE 200 MG TABLET", "drug_information": { "unit": "200", "type": "UN" }, "code_information": [ { "code": "51672400501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFAZOLIN 1 GM/VIAL, J0690 - INJECTION, PER 500 MG", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "60505074905", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378087199", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEPHALEXIN 250 MG CAPSULE", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "00093314501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEPACOL SORE THROAT (BENZOCAINE-MENTHOL) 15 MG-3.6 MG LOZENGES", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "63824071316", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACTIDOSE/SORBITOL 25 GRAM/120 ML ORAL SUSPENSION", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00574012074", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHLORDIAZEPOXIDE 25 MG CAPSULE", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "51079014120", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHLORDIAZEPOXIDE 5 MG CAPSULE", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "51079037420", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3230 - Injection, chlorpromazine hcl, up to 50 mg", "drug_information": { "unit": "25", "type": "GR" }, "code_information": [ { "code": "00641139735", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FIBERCON 625 MG TABLET", "drug_information": { "unit": "625", "type": "UN" }, "code_information": [ { "code": "00904250091", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1100 - Injection, dexamethasone sodium phosphate, 1mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "63323016501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "COLCRYS 0.6 MG TABLET", "drug_information": { "unit": "0.6", "type": "UN" }, "code_information": [ { "code": "64764011907", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1327 - Injection, eptifibatide, 5 mg", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00085113601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LOSARTAN 50 MG TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "63739068610", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CYCLOBENZAPRINE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "51079064420", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J0895 - Injection, deferoxamine mesylate, 500 mg", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00409233610", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXAMETHASONE 4 MG TABLET", "drug_information": { "unit": "4", "type": "UN" }, "code_information": [ { "code": "00054418425", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXTROSE 50%-WATER SYRINGE", "drug_information": { "unit": "50", "type": "ML" }, "code_information": [ { "code": "00409751716", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXTROSE 5%-WATER IV SOLN (100 MILLILITERS)", "drug_information": { "unit": "100", "type": "ML" }, "code_information": [ { "code": "00409792337", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXTROSE 5%-WATER IV SOLN (1000 MILLILITERS)", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409792209", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIAZEPAM 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "63739007310", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DICYCLOMINE 20 MG TABLET", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00378162001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1160 - Injection, digoxin, up to 0.5 mg", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00641141035", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIGOX 125 MCG TABLET", "drug_information": { "unit": "125", "type": "UN" }, "code_information": [ { "code": "00527132401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIGOX 250 MCG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "00527132501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00641601310", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DILTIAZEM 60 MG TABLET", "drug_information": { "unit": "60", "type": "UN" }, "code_information": [ { "code": "00378004501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1200 - Injection, diphenhydramine hcl, up to 50 mg", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "00641037625", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378041501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1250 - Injection, dobutamine hydrochloride, per 250 mg", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "00409202520", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DOCUSATE CALCIUM 240 MG CAPSULE", "drug_information": { "unit": "240", "type": "UN" }, "code_information": [ { "code": "00536106501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DOCUSATE SODIUM 100 MG CAPSULE", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "63739047840", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1265 - Injection, dopamine hcl, 40 mg", "drug_information": { "unit": "40", "type": "ML" }, "code_information": [ { "code": "00338100702", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LEVETIRACETAM 500 MG TAB", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "63739041110", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DILTIAZEM ER (XR/XT) 120 MG CAPSULE,EXTENDED RELEASE,CONTROLLED", "drug_information": { "unit": "120", "type": "GR" }, "code_information": [ { "code": "00378522001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1956 - Injection, levoflaxacin, 250 mg", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "00781334109", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DOXEPIN 25 MG CAPSULE", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "00378312501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2020 - Injection, linezolid, 200 mg", "drug_information": { "unit": "200", "type": "ML" }, "code_information": [ { "code": "00009514001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FENTANYL 25 MCG/HR TRANSDERMAL PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00406902576", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FENTANYL 50 MCG/HR TRANSDERMAL PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00406905076", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2060 - Injection, lorazepam, 2mg", "drug_information": { "unit": "2", "type": "ML" }, "code_information": [ { "code": "00641604425", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ENALAPRIL MALEATE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "64679092402", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J7699 - Noc drugs, inhalation solution administered through dme", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "00487590199", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J0171 - Injection, adrenalin, epinephrine, 0.1 mg", "drug_information": { "unit": "0.1", "type": "GR" }, "code_information": [ { "code": "00409724101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MEROPENEM 100MG IV", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "25021015515", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MEGESTROL 400 MG/10 ML (40 MG/ML) ORAL SUSPENSION", "drug_information": { "unit": "10", "type": "ML" }, "code_information": [ { "code": "49884090738", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ERYTHROCIN 500 MG INTRAVENOUS SOLUTION", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "00409647644", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FAMOTIDINE 20 MG TABLET", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00172572860", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL SOLUTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00536065085", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLAVOXATE 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "00574011501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLUDROCORTISONE 0.1 MG TABLET", "drug_information": { "unit": "0.1", "type": "UN" }, "code_information": [ { "code": "00555099702", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OLANZAPINE 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "GR" }, "code_information": [ { "code": "00093576756", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CITALOPRAM 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "13668000901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIVALPROEX 125 MG TABLET,DELAYED RELEASE", "drug_information": { "unit": "125", "type": "GR" }, "code_information": [ { "code": "62756079688", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1335 - Injection, ertapenem sodium, 500 mg", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00006384371", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FOLIC ACID 1 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "62584089701", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ENALAPRILAT 1.25 MG/ML INTRAVENOUS", "drug_information": { "unit": "1.25", "type": "ML" }, "code_information": [ { "code": "00143978710", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLINDAMYCIN 150 MG CAPSULE", "drug_information": { "unit": "150", "type": "GR" }, "code_information": [ { "code": "59762332801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "51079016120", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FUROSEMIDE 40 MG TABLET", "drug_information": { "unit": "40", "type": "UN" }, "code_information": [ { "code": "63304062501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CELEBREX 100 MG CAPSULE", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "00025152034", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLUOXETINE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "00904578461", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GABAPENTIN 300 MG CAPSULE", "drug_information": { "unit": "300", "type": "UN" }, "code_information": [ { "code": "49483060650", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1580 - Injection, garamycin, gentamicin, up to 80 mg", "drug_information": { "unit": "80", "type": "GR" }, "code_information": [ { "code": "63323001002", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GLIPIZIDE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00591046001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1610 - Injection, glucagon hydrochloride, per 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00597026010", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GUAIFENESIN ER 600 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "600", "type": "GR" }, "code_information": [ { "code": "45802049878", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLUCONAZOLE 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "68462010230", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HALOPERIDOL 2 MG TABLET", "drug_information": { "unit": "2", "type": "UN" }, "code_information": [ { "code": "00378021401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1630 - Injection, haloperidol, up to 5mg", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "50458025501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1631 - Injection, haloperidol decanoate, per 50 mg", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "10147092103", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1644 - Injection, heparin sodium, per 1000 units", "drug_information": { "unit": "1000", "type": "F2" }, "code_information": [ { "code": "63323054201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J0360 - Injection, hydralazine, hcl, up to 20 mg", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "63323061401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HYDRALAZINE 10 MG TABLET", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "49884002901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HYDRALAZINE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "50111032701", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HYDROCHLOROTHIAZIDE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "63739012810", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1720 - Injection, hydrocortisone sodium succinate, up to 100 mg", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "00009082501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CAPTOPRIL 12.5 MG TABLET", "drug_information": { "unit": "12.5", "type": "UN" }, "code_information": [ { "code": "00143117101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "IBUPROFEN 400 MG TABLET", "drug_information": { "unit": "400", "type": "UN" }, "code_information": [ { "code": "00904585340", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "IBUPROFEN 200 MG TABLET", "drug_information": { "unit": "200", "type": "UN" }, "code_information": [ { "code": "00904791540", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "IBUPROFEN 800 MG TABLET", "drug_information": { "unit": "800", "type": "UN" }, "code_information": [ { "code": "53746046605", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3030 - Injection, sumatriptan succinate, 6 mg", "drug_information": { "unit": "6", "type": "GR" }, "code_information": [ { "code": "00143963805", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INDOMETHACIN 25 MG CAPSULE", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "00093402901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DICYCLOMINE 10 MG/ML, J0500 - INJECTION, UP TO 20 MG", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "58914008052", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3260 - Injection, tobramycin sulfate, up to 80 mg", "drug_information": { "unit": "80", "type": "GR" }, "code_information": [ { "code": "39822041201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ISONIAZID 300 MG TABLET", "drug_information": { "unit": "300", "type": "UN" }, "code_information": [ { "code": "00555007101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "unit": "60", "type": "UN" }, "code_information": [ { "code": "62175011937", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "M-M-R II (PF) 1,000-12,500 TCID50/0.5 ML SUBCUTANEOUS SOLUTION", "drug_information": { "unit": "0.5", "type": "UN" }, "code_information": [ { "code": "00006468100", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DAPTACEL (DTAP PEDIATRIC) (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "58160081052", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LABETALOL 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "00409226720", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ONDANSETRON 4 MG DISINTEGRATING TABLET", "drug_information": { "unit": "4", "type": "UN" }, "code_information": [ { "code": "68462015740", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LACTULOSE 10 GRAM/15 ML ORAL SOLUTION", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "00603137858", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "62756046188", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00228254010", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LEVOTHYROXINE 25 MCG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "51079044420", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LEVOTHYROXINE 88 MCG TABLET", "drug_information": { "unit": "88", "type": "UN" }, "code_information": [ { "code": "00527134401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LEVOTHYROXINE 50 MCG TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "00527134201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VALPROATE 500MG/5ML IV", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00143963710", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LISINOPRIL 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "63739034910", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LITHIUM CARBONATE 150 MG CAPSULE", "drug_information": { "unit": "150", "type": "UN" }, "code_information": [ { "code": "00054252625", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LOPERAMIDE 2 MG CAPSULE", "drug_information": { "unit": "2", "type": "UN" }, "code_information": [ { "code": "00378210001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LORAZEPAM 1 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "63739050010", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1650 - Injection, enoxaparin sodium, 10 mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00781313363", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1650 - Injection, enoxaparin sodium, 10 mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00781322464", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3475 - Injection, magnesium sulfate, per 500 mg", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "63323006402", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MECLIZINE 25 MG CHEWABLE TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "50268052315", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MEDROXYPROGESTERONE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "59762374101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2175 - Injection, meperidine hydrochloride, per 100 mg", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "00641605325", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METHOCARBAMOL 10ML", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00641610325", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METHOCARBAMOL 500 MG TABLET", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "00603448521", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METHOTREXATE SODIUM 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "UN" }, "code_information": [ { "code": "00378001401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METHYLPREDNISOLONE 4 MG TABLET", "drug_information": { "unit": "4", "type": "UN" }, "code_information": [ { "code": "00603459321", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00409341401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METOLAZONE 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "UN" }, "code_information": [ { "code": "00378617201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METRONIDAZOLE 250 MG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "50111033306", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METFORMIN 850 MG TABLET", "drug_information": { "unit": "850", "type": "UN" }, "code_information": [ { "code": "57664043551", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METFORMIN 500 MG TABLET", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "00093104801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2250 - Injection, midazolam hydrochloride, per 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "57664063343", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MAGNESIUM OXIDE 400 MG TABLET", "drug_information": { "unit": "400", "type": "UN" }, "code_information": [ { "code": "63739035410", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2270 - Injection, morphine sulfate, up to 10mg", "drug_information": { "unit": "4", "type": "GR" }, "code_information": [ { "code": "00641612525", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN B-12 1,000 MCG TABLET", "drug_information": { "unit": "1000", "type": "UN" }, "code_information": [ { "code": "00536355601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TAB-A-VITE TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00904053060", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NAPROXEN 250 MG TABLET", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "00093014701", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2710 - Injection, neostigmine methylsulfate, up to 0.5 mg", "drug_information": { "unit": "0.5", "type": "GR" }, "code_information": [ { "code": "43598052836", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "30", "type": "UN" }, "code_information": [ { "code": "50742062001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROSTAT 0.4 MG SUBLINGUAL TABLET", "drug_information": { "unit": "0.4", "type": "UN" }, "code_information": [ { "code": "00071041824", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378911293", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITRO-BID 2 % TRANSDERMAL OINTMENT", "drug_information": { "unit": "60", "type": "GR" }, "code_information": [ { "code": "00281032660", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378910493", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378910293", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "00338104902", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROPRESS 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "00187430202", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LABETALOL 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "00172436460", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "60505006502", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2360 - Injection, orphenadrine citrate, up to 60 mg", "drug_information": { "unit": "60", "type": "GR" }, "code_information": [ { "code": "00591322247", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OXYBUTYNIN CHLORIDE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "50111045601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OXYCODONE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00406055262", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2590 - Injection, oxytocin, up to 10 units", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "63323001201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PAROXETINE 20 MG TABLET", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "00093711598", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PENICILLIN V POTASSIUM 250 MG TABLET", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "00093117201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TEMAZEPAM 15 MG CAPSULE", "drug_information": { "unit": "15", "type": "UN" }, "code_information": [ { "code": "51079041820", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHENAZOPYRIDINE 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "42937070110", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHENOBARBITAL 32.4 MG TABLET", "drug_information": { "unit": "32.4", "type": "UN" }, "code_information": [ { "code": "63739020110", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "68084037601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1165 - Injection, phenytoin sodium, per 50 mg", "drug_information": { "unit": "50", "type": "ML" }, "code_information": [ { "code": "39822405006", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHENYTOIN 125 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "51672406901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DILANTIN INFATABS 50 MG CHEWABLE TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "00071000724", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2560 - Injection, phenobarbital sodium, up to 120 mg", "drug_information": { "unit": "65", "type": "ML" }, "code_information": [ { "code": "00641047625", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2370 - Injection, phenylephrine, hcl, up to 1 ml", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00641614225", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3430 - Injection, phytonadione (vitamin k), per 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00409915701", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "K-TAB 10 MEQ TABLET,EXTENDED RELEASE", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "00074780413", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "00603154258", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00245531901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SSKI 1 GRAM/ML ORAL SOLUTION", "drug_information": { "unit": "30", "type": "ML" }, "code_information": [ { "code": "00245000331", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN", "drug_information": { "unit": "120", "type": "ML" }, "code_information": [ { "code": "50383004004", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROCHLORPERAZINE MALEATE 25 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "25", "type": "GR" }, "code_information": [ { "code": "00713013512", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROCHLORPERAZINE MALEATE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00378510501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROCHLORPERAZINE 10 MG/2 ML VL 5 ea, 2 mL", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "23155029442", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROMETHAZINE-CODEINE 6.25 MG-10 MG/5 ML SYRUP", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "00603158558", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3486 - Injection, ziprasidone mesylate, 10 mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00049392083", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHENADOZ 25 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "25", "type": "GR" }, "code_information": [ { "code": "00591299239", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROMETHEGAN 50 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "00713013212", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROMETHAZINE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "00591530701", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2550 - Injection, projethazine hcl, up to 50 mg", "drug_information": { "unit": "25", "type": "GR" }, "code_information": [ { "code": "00641092825", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2704 - Injection, propofol, 10 mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00409469930", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1800 - Injection, propranolol hcl, up to 1mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "63323060401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROPRANOLOL 40 MG TABLET", "drug_information": { "unit": "40", "type": "UN" }, "code_information": [ { "code": "50268070215", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2720 - Injection, protamine sulfate, per 10 mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "63323022930", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SUDOGEST 30 MG TABLET", "drug_information": { "unit": "30", "type": "UN" }, "code_information": [ { "code": "00904505359", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "QUINIDINE GLUCONATE ER 324 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "324", "type": "UN" }, "code_information": [ { "code": "53489014101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "RANITIDINE 150 MG TABLET", "drug_information": { "unit": "150", "type": "UN" }, "code_information": [ { "code": "63739048910", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "RIFAMPIN 300 MG CAPSULE", "drug_information": { "unit": "300", "type": "UN" }, "code_information": [ { "code": "00185079930", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "RISPERIDONE 1 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "13668003760", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "unit": "0.5", "type": "GR" }, "code_information": [ { "code": "00143978410", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SILVADENE 1 % TOPICAL CREAM", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "61570013120", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLONIDINE HCL 0.1 MG TABLET", "drug_information": { "unit": "0.1", "type": "UN" }, "code_information": [ { "code": "00228212710", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378087299", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GAS RELIEF 80 MG CHEWABLE TABLET", "drug_information": { "unit": "80", "type": "GR" }, "code_information": [ { "code": "57896079101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BENZONATATE 100 MG CAPSULE", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "67877010501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "76329335201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SPIRONOLACTONE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "00603576321", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20MG", "drug_information": { "unit": "200", "type": "GR" }, "code_information": [ { "code": "00409662902", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SUCRALFATE 1 GRAM TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00093221001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SIMVASTATIN 20 MG TABLET", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "68180047901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TRAMADOL 50 MG TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "57664037708", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROPYLTHIOURACIL 50 MG TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "00228234810", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TERAZOSIN 1 MG CAPSULE", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00904612661", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3105 - Injection, terbutaline sulfate, up to 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "63323066501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TERBUTALINE 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "UN" }, "code_information": [ { "code": "00527131801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GLIMEPIRIDE 1 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00093725401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FENTANYL 12 MCG/HR TRANSDERMAL PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00781724055", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "THEOPHYLLINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "50111048301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "unit": "300", "type": "UN" }, "code_information": [ { "code": "50111045901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3411 - Injection, thiamine hcl, 100 mg", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "63323001302", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TRAZODONE 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "50111043401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00003029328", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00378135501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TUSSIONEX PENNKINETIC ER 8 MG-10 MG/5 ML SUSPENSION,EXTENDED RELEASE", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "53014054801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VERAPAMIL 80 MG TABLET", "drug_information": { "unit": "80", "type": "UN" }, "code_information": [ { "code": "00378051201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00121067516", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "180", "type": "UN" }, "code_information": [ { "code": "00093304401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "240", "type": "UN" }, "code_information": [ { "code": "68462026001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00409114405", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "WARFARIN 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "UN" }, "code_information": [ { "code": "00056017675", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "COUMADIN 2 MG TABLET", "drug_information": { "unit": "2", "type": "UN" }, "code_information": [ { "code": "00056017075", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "COUMADIN 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00056017275", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "41616093144", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MILK OF MAGNESIA 400 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "00536247085", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN B-6 50 MG TABLET", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "00536440801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PEPTO-BISMOL 262 MG/15 ML ORAL SUSPENSION", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "37000003204", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GLUTOSE 15 40 % ORAL GEL", "drug_information": { "unit": "15", "type": "UN" }, "code_information": [ { "code": "00574006930", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3370 - Injection, vancomycin hcl, 500 mg", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00409653301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LEVAQUIN 250 MG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "68084048101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "S5010 - 5% dextrose and 0.45% normal saline, 1000 ml", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409792609", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J7030 - Infusion, normal saline solution, 1000cc", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409798309", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409798509", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J7120 - Ringers lactate infusion, up to 1000 cc", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409795309", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFEPIME 1 GM/VIAL, J0692 - INJECTION, PER 500 MG", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "25021012120", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SOTALOL 80 MG TABLET", "drug_information": { "unit": "80", "type": "UN" }, "code_information": [ { "code": "00603576921", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMLODIPINE 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "UN" }, "code_information": [ { "code": "00904636961", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PREDNISOLONE 15 MG/5 ML ORAL SOLUTION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "00093611816", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00406012362", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VANCOMYCIN 125 MG CAPSULE", "drug_information": { "unit": "125", "type": "UN" }, "code_information": [ { "code": "47781072902", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00406051262", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MEPHYTON 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00187170405", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMIODARONE 200 MG TABLET", "drug_information": { "unit": "200", "type": "UN" }, "code_information": [ { "code": "00093913306", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SENNA 8.8 MG/5 ML SYRUP", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "57896045208", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3101 - Injection, tenecteplase, 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "50242012001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00245053660", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METOPROLOL 5 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "63323066005", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACYCLOVIR 500 MG/VIAL, J0133 - INJECTION, PER 5 MG", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "63323032510", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ADACEL (TDAP) 0.5 ML/SYRINGE, 90715 - INJECTION, 7 YRS AND OLDER", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "49281040015", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALPRAZOLAM 0.5 MG TABLET", "drug_information": { "unit": "0.5", "type": "UN" }, "code_information": [ { "code": "51079078920", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALPRAZOLAM 0.25 MG TABLET", "drug_information": { "unit": "0.25", "type": "UN" }, "code_information": [ { "code": "00904585861", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ASPIRIN 81 MG CHEWABLE TABLET", "drug_information": { "unit": "81", "type": "UN" }, "code_information": [ { "code": "00904404073", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ATORVASTATIN 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "60505257809", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ATROPINE SULFATE 1 MG/10 ML (0.1 MG/ML), J0461 - INJECTION, 0.01 MG", "drug_information": { "unit": "0.01", "type": "GR" }, "code_information": [ { "code": "76329333901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CALTRATE-600 + D VIT D3 (800) 600 MG (1,500 MG)-800 UNIT TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00005550924", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CARVEDILOL 3.125 MG TABLET", "drug_information": { "unit": "3.125", "type": "UN" }, "code_information": [ { "code": "68462016201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CLOPIDOGREL 75 MG TABLET", "drug_information": { "unit": "75", "type": "UN" }, "code_information": [ { "code": "47335089481", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DONEPEZIL 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "62756044083", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DONNATAL 16.2 MG-0.1037MG-0.0194MG/5ML ORAL ELIXIR", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "59212042204", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DULCOLAX (BISACODYL) 5 MG TABLET,DELAYED RELEASE", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "49348003210", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ENGERIX-B (PF) 20 MCG/ML INTRAMUSCULAR SUSPENSION", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "58160082111", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FERROUS SULFATE 325 MG (65 MG IRON) TABLET", "drug_information": { "unit": "325", "type": "GR" }, "code_information": [ { "code": "64376080910", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FINASTERIDE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "76282041230", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FUROSEMIDE 20 MG TABLET", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00054429725", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GABAPENTIN 100 MG CAPSULE", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "59762502601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHLORPHENIRAMINE 8 MG-HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR", "drug_information": { "unit": "115", "type": "ML" }, "code_information": [ { "code": "62175049064", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "KIONEX 15 GRAM/60 ML ORAL SUSPENSION", "drug_information": { "unit": "15", "type": "GR" }, "code_information": [ { "code": "00574200216", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LISINOPRIL 40 MG TABLET", "drug_information": { "unit": "40", "type": "UN" }, "code_information": [ { "code": "00603421421", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MACRODANTIN 50 MG CAPSULE", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "52427028701", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MARCAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION", "drug_information": { "unit": "10", "type": "ML" }, "code_information": [ { "code": "00409116301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METOCLOPRAMIDE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00093220401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METOPROLOL TARTRATE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "63304057901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MI-ACID 200 MG-200 MG-20 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "355", "type": "ML" }, "code_information": [ { "code": "00904000414", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MONTELUKAST 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "42291062130", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MS CONTIN 15 MG TABLET,EXTENDED RELEASE", "drug_information": { "unit": "15", "type": "GR" }, "code_information": [ { "code": "59011026010", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "S0032 - Injection, nafcillin sodium, 2 grams", "drug_information": { "unit": "2", "type": "GR" }, "code_information": [ { "code": "00781312595", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "51672411709", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OLANZAPINE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00093576856", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER", "drug_information": { "unit": "17", "type": "GR" }, "code_information": [ { "code": "51991045757", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PREDNISONE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "00054001720", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PREDNISONE 20 MG TABLET", "drug_information": { "unit": "20", "type": "UN" }, "code_information": [ { "code": "00591544301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SANI-SUPP (ADULT) RECTAL", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00713010109", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SENNA PLUS 8.6 MG-50 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00904633961", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SERTRALINE 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "68180035109", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SILACE 60 MG/15 ML SYRUP", "drug_information": { "unit": "473", "type": "GR" }, "code_information": [ { "code": "54838010780", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FIBER SMOOTH ORAL POWDER", "drug_information": { "unit": "15", "type": "UN" }, "code_information": [ { "code": "49348009168", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "IBUPROFEN 100 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "49348022934", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LORATADINE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "16714048202", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SENNA LAXATIVE 8.6 MG TABLET", "drug_information": { "unit": "8.6", "type": "UN" }, "code_information": [ { "code": "49348006210", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SPIRONOLACTONE 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "00228267311", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "50383082416", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TAMSULOSIN ER 0.4 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "unit": "0.4", "type": "UN" }, "code_information": [ { "code": "00781207601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TRANSDERM-SCOP 1.5 MG TRANSDERMAL 72 HOUR PATCH", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "10019055303", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN B-1 100 MG TABLET", "drug_information": { "unit": "100", "type": "UN" }, "code_information": [ { "code": "00904054460", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN C 250 MG CHEWABLE TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "00904052560", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN D3 1,000 UNIT TABLET", "drug_information": { "unit": "1000", "type": "UN" }, "code_information": [ { "code": "00904582460", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFUROXIME 1.5 GM/VIAL, J0697 - INJECTION, PER 750 MG", "drug_information": { "unit": "750", "type": "GR" }, "code_information": [ { "code": "25021011920", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3489 - Injection, zoledronic acid, 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "67457039054", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ZOLPIDEM 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "68084018901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MELATONIN 3MG TAB", "drug_information": { "unit": "3", "type": "UN" }, "code_information": [ { "code": "00904518252", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "EXCIS PILONIDL CYST/SINUS", "code_information": [ { "code": "10021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXPLORE PENETRATING WOUND", "code_information": [ { "code": "20103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY", "code_information": [ { "code": "G0168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "I\u0026D PERIANAL ABSCESS SUPR", "code_information": [ { "code": "46050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "INJECT, CARPAL TUNNEL", "code_information": [ { "code": "20526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "INJECT, SINGLE TENDON", "code_information": [ { "code": "20551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "PROSTATIC ACID PHOSPHATASE (PAP)", "code_information": [ { "code": "84066", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "ACTH, PLASMA", "code_information": [ { "code": "82024", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 382, "minimum": 382 } ] }, { "description": "BIOTINIDASE", "code_information": [ { "code": "82261", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "ALPHA-FETOPROTEIN (AFP) AND AFP-L3", "code_information": [ { "code": "82107", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "AMITRIPTYLINE", "code_information": [ { "code": "80335", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "ALBUMIN, PERITONEAL FLUID", "code_information": [ { "code": "82042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "ALDOLASE", "code_information": [ { "code": "82085", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "ALKALINE PHOSPHATASE, BONE SPECIFIC", "code_information": [ { "code": "84075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "Lactoferrin, qualitative, stool", "code_information": [ { "code": "83630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 231, "minimum": 231 } ] }, { "description": "ALKALINE PHOSPHATASE ISOENZYMES 1", "code_information": [ { "code": "84075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "ALLERGEN CODFISH (F3)", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "ALLERGEN FOODS PANEL", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 316, "minimum": 316 } ] }, { "description": "WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY", "code_information": [ { "code": "G0168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "HAVRIX (PF) 720 ELISA UNIT/0.5 ML INTRAMUSCULAR SYRINGE", "code_information": [ { "code": "90633", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 56, "minimum": 56 } ] }, { "description": "VARIVAX (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSPENSION", "code_information": [ { "code": "90716", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 93, "minimum": 93 } ] }, { "description": "AZMACORT INHALER", "code_information": [ { "code": "J7684", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "GI COCKTAIL", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU", "code_information": [ { "code": "J2724", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "SINGULAIR 10 MG TAB", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "CROMOLYN NA 20 MG/2CC", "code_information": [ { "code": "J7632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8, "minimum": 8 } ] }, { "description": "VENLAFAXINE 37.5 MG TAB", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6, "minimum": 6 } ] }, { "description": "Injection, prochlorperazine, up to 10 mg", "code_information": [ { "code": "J0780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 61, "minimum": 61 } ] }, { "description": "ADMINISTRATION OF INFLUENZA VIRUS VACCINE", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 29, "minimum": 29 } ] }, { "description": "PROTONIX DELAYED RELEASE TAB 40 MG PO", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 16, "minimum": 16 } ] }, { "description": "ELIQUIS 2.5 MG TABLET", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 10, "minimum": 10 } ] }, { "description": "JARDIANCE 10 MG TAB", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 17, "minimum": 17 } ] }, { "description": "ADULT ROBITUSSIN NIGHT M-S COLD 6.25 MG-2.5 MG-160 MG/5 ML ORAL LIQUID", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2, "minimum": 2 } ] }, { "description": "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6, "minimum": 6 } ] }, { "description": "GEMFIBROZIL 600 MG TAB", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 0.5, "minimum": 0.5 } ] }, { "description": "CALCIUM MAGNESIUM ZINC", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2, "minimum": 2 } ] }, { "description": "ABX SUPPORT 10+ BILLION CFU", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4, "minimum": 4 } ] }, { "description": "THER-BIOTIC 25+ BILLION CFU", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3, "minimum": 3 } ] }, { "description": "TRUVADA (EMTRICITABINE AND TENOFOVIR) 200/300 MG", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "ISENTRESS (RALTEGRAVIR) 400 MG", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 49, "minimum": 49 } ] }, { "description": "LINEZOLID 600 MG TAB", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "OSTEO BIFLEX CAPSULE", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2, "minimum": 2 } ] }, { "description": "CLOBETASOL PROPRINATE 15 GM TUBE", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "INJ,\u003e=1 TRIG PT,\u003e=3 MUSCL", "code_information": [ { "code": "20553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVAL IMPLANT, SUPERFIC", "code_information": [ { "code": "20670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "DEBRIDE INC REMOV FOREIGN", "code_information": [ { "code": "11012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "DEBRIDE ECZEM SKIN ADD\u0027L", "code_information": [ { "code": "11001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SUBLUNGUAL HEMATOMA", "code_information": [ { "code": "11740", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR LACER \u003c=2.5 MOUTH", "code_information": [ { "code": "41250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SHAVE BX TRUNK \u003c0.5CM", "code_information": [ { "code": "11300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SHAVE BX TRUNK 0.6-1.00CM", "code_information": [ { "code": "11301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SHAVE BX TRUNK 1.1-2.0CM", "code_information": [ { "code": "11302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SHAVE EPIDERM LESION .5CM", "code_information": [ { "code": "11310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SPLIT GRAFT 1ST 100 SQ CM", "code_information": [ { "code": "15100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "FULL THCK GRAFT TRNK\u003c20CM", "code_information": [ { "code": "15200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "DRESS CHG UNDER ANESTHES", "code_information": [ { "code": "15852", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "I \u0026 D OF BURNS SAMLL", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "INSJ NON-NDWELLG BLADDER CATHETER", "code_information": [ { "code": "51701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 204, "minimum": 204 } ] }, { "description": "BLADDER INSTILLATION", "code_information": [ { "code": "51720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXC PILONIDAL CYST XTENSV", "code_information": [ { "code": "11771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "EXCISION TUMOR BACK/FLANK", "code_information": [ { "code": "21930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "LAYER CLOSURE, 20.1-30CM", "code_information": [ { "code": "12036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "TRIGGER POINT SINGLE OR M", "code_information": [ { "code": "20552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "ASPIR/INJEC GANGLION CYST", "code_information": [ { "code": "20612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SIALOLITHOTOMY UNCOMPLICA", "code_information": [ { "code": "42330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "THORACENTESIS ASPIRATION", "code_information": [ { "code": "32554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "T/X ELBOW DISLOCAT W/O AN", "code_information": [ { "code": "24600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOSED TREAT RADIAL HEAD", "code_information": [ { "code": "24640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "RADIAL HEAD W/O MAL", "code_information": [ { "code": "24650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXCISION GANGLION CYST WR", "code_information": [ { "code": "25111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "CLOSED TX OF RADIAL", "code_information": [ { "code": "25565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "DRAIN,FINGER ABCESS,SIMP", "code_information": [ { "code": "26010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXC LES OF TENDON SHEATH", "code_information": [ { "code": "26160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "CLOSED T/X METACARPAL FRA", "code_information": [ { "code": "26600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "OPEN TXT DIST PHALANG FX", "code_information": [ { "code": "26765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "CLOSED TREAT PATELLAR DIS", "code_information": [ { "code": "27560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CTRL NASOPHARYNG HEMORRHA", "code_information": [ { "code": "42970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DRAIN ABCESS NASAL INTERA", "code_information": [ { "code": "30000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "TUBE THORACOSTOMY", "code_information": [ { "code": "32551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "REPAIR CMPLX EA ADDL\u003c=5CM", "code_information": [ { "code": "13153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOS TX SHLDR DISLOC,ANES", "code_information": [ { "code": "23655", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "DILATE FEMALE URETH, INIT", "code_information": [ { "code": "53660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DILATE FEMALE URETH SUBSQ", "code_information": [ { "code": "53661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "GASTRIC INTUBATION AND APSIRATION", "code_information": [ { "code": "43753", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "LIGATION VARICOSE VEIN", "code_information": [ { "code": "37785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "Injection, anesthetic agent; trigeminal nerve, any division or branch", "code_information": [ { "code": "64400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "INJ, ANES AGENT ILIO NRVS", "code_information": [ { "code": "64425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "I \u0026 D TRANSRECTAL ABCESS", "code_information": [ { "code": "45005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "I\u0026D DEEP SUPRALEVATOR ABS", "code_information": [ { "code": "45020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS", "code_information": [ { "code": "46230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2992, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2930, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2744, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3150, "minimum": 3150 } ] }, { "description": "MEATOTOMY, CUTTING MEATUS", "code_information": [ { "code": "53020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "EXCISE,LESION,\u003e4 CM", "code_information": [ { "code": "11446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "REMOVE RECTAL OBSTRUCTION", "code_information": [ { "code": "45915", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "CURETTAGE POSTPARTUM", "code_information": [ { "code": "59160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "THORACENTESIS,INT/OR SUB", "code_information": [ { "code": "32554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "I\u0026D COMPLEX,WOUND INF", "code_information": [ { "code": "10180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "REMOVE F/B SUBQ COMP", "code_information": [ { "code": "10121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "I\u0026D HEMOTOMA,FLUID RET", "code_information": [ { "code": "10140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "DEBRIDEMENT 10% BODY SURF", "code_information": [ { "code": "11000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DEBRIDE, SUBQ TISSUE", "code_information": [ { "code": "11042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVE F/B MOUTH COMPLEX", "code_information": [ { "code": "40805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "REMOVE, SKIN TAGS TO 15", "code_information": [ { "code": "11200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXCISE LESION \u003c=0.5CM", "code_information": [ { "code": "11400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE, LESION, 0.6-1.0CM", "code_information": [ { "code": "11401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE, LESION 1.1-2.0 CM", "code_information": [ { "code": "11402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE, LESION, 2.1-3.0CM", "code_information": [ { "code": "11403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION 3.1-4.0CM", "code_information": [ { "code": "11404", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISE,LESION,\u003e4.0CM", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISE, LESION \u003c=0.5CM", "code_information": [ { "code": "11420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "GLUCOSE TOL 2 HR BLOOD", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "CHLAMYDIA, RNA", "code_information": [ { "code": "87491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "GLUCOSE TOL 1 HR BLOOD", "code_information": [ { "code": "82950", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "BCR-ABL1 GENE REARRANGEMENT, QUANTITATIVE, PCR", "code_information": [ { "code": "81206", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "MICROALBUMIN", "code_information": [ { "code": "82043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 86, "minimum": 86 } ] }, { "description": "ERRG - URINE DRUG COLLECTION", "code_information": [ { "code": "99001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "GLUCOSE TOL 3 HR BLOOD", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "GLUCOSE TOL 4 HR BLOOD", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "GLUCOSE TOL FASTING BLOOD", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "LIVER KIDNEY MICROSOMAL (LKM-1) ANTIBODY (IGG)", "code_information": [ { "code": "86376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "WOUND CULTURE", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "RENIN, PLASMA", "code_information": [ { "code": "84244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "PERIPHERAL BLOOD SMEAR", "code_information": [ { "code": "85060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "CALCIUM, RANDOM URINE", "code_information": [ { "code": "82310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "TRACHOMATIS, RNA", "code_information": [ { "code": "87591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 107, "minimum": 107 } ] }, { "description": "OVA AND PARASITES O+P CONCENTRATE", "code_information": [ { "code": "87015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "ALLERGY PANEL 18, NUT MIX GROUP", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "MUMPS VIRUS ANTIBODY (IGG)", "code_information": [ { "code": "86735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 44, "minimum": 44 } ] }, { "description": "HEPATITIS B VIRUS DNA, QUANTITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87517", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 684, "minimum": 684 } ] }, { "description": "CRYPTOCOCCAL ANTIGEN, LATEX SCREEN WITH REFLEX TO TITER", "code_information": [ { "code": "86403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "TOXOPLASMA ANTIBODY (IGG)", "code_information": [ { "code": "86777", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "VARICELLA-ZOSTER VIRUS ANTIBODY (IGM)", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "TOXOPLASMA ANTIBODY (IGM)", "code_information": [ { "code": "86778", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "MYELOPEROXIDASE ANTIBODY (MPO)", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "LEGIONELLA ANTIGEN, EIA, URINE", "code_information": [ { "code": "87449", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "Everolimus, LC/MS/MS, Blood", "code_information": [ { "code": "80169", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 259, "minimum": 259 } ] }, { "description": "TRANSFERRIN", "code_information": [ { "code": "84466", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "Soluble Liver Antigen (SLA) Autoantibody", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "ADENOVIRUS ANTIGEN DETECTION, GASTROENTERITIS, EIA", "code_information": [ { "code": "87301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "HCG WITH GESTATIONAL TABLE", "code_information": [ { "code": "84702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "ANTIBODY SCREEN, RBC WITH REFLEX TO IDENTIFICATION, TITER, AND ANTIGEN TYPING", "code_information": [ { "code": "86850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "ADENOVIRUS DNA, QUANTITATIVE REAL-TIME PCR", "code_information": [ { "code": "87799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 769, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 769, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 769, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 752, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 705, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 809, "minimum": 809 } ] }, { "description": "CYOPRECIPIATED AHF", "code_information": [ { "code": "P9012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "FRESH FROZEN PLASMA, THAW", "code_information": [ { "code": "86927", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "FRESH FROZEN PLASMA", "code_information": [ { "code": "P9017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "PLATELETS ADMIN SET", "code_information": [ { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "BLOOD ADMINISTRATION", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 621, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 582, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 668, "minimum": 668 } ] }, { "description": "BLOOD ADMINISTRATION", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 952, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 952, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 952, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 932, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 873, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1002, "minimum": 1002 } ] }, { "description": "BLOOD ADMINISTRATION", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1271, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1271, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1271, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1244, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1338, "minimum": 1338 } ] }, { "description": "BLOOD ADMINISTRATION", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1590, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1590, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1590, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1557, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1458, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1674, "minimum": 1674 } ] }, { "description": "BLOOD ADMINISTRATION", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1909, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1909, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1909, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1868, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1750, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 703, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 703, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 703, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 703, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 703, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2009, "minimum": 2009 } ] }, { "description": "BLOOD ADMINISTRATION", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2041, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2343, "minimum": 2343 } ] }, { "description": "PROCESSING AND STORAGE", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 832, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 832, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 832, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 815, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 763, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 876, "minimum": 876 } ] }, { "description": "PROCESSING AND STORAGE", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1663, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1663, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1663, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1628, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1524, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 613, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 613, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 613, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 613, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 613, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1750, "minimum": 1750 } ] }, { "description": "PROCESSING AND STORAGE", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2494, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2494, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2494, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2441, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2286, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 919, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 919, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 919, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 919, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 919, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2625, "minimum": 2625 } ] }, { "description": "PROCESSING AND STORAGE", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3327, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3327, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3327, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3257, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3050, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3502, "minimum": 3502 } ] }, { "description": "PROCESSING AND STORAGE", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4071, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3812, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1532, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1532, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1532, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1532, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1532, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4377, "minimum": 4377 } ] }, { "description": "PROCESSING AND STORAGE", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4988, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4988, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4988, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4883, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4574, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1838, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1838, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1838, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1838, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1838, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 5251, "minimum": 5251 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11421", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION,1.1-2.0CM", "code_information": [ { "code": "11422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION,2.1-3 CM", "code_information": [ { "code": "11423", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISE,LESION,3.1-4 CM", "code_information": [ { "code": "11424", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "REMOVE FB CONJUNCT EMBED", "code_information": [ { "code": "65210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "SPINAL PUNCTURE DIAGNOSTI", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE,LESION,4.0 CM", "code_information": [ { "code": "11426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "EXCISE,LESION,\u003c=.05CM", "code_information": [ { "code": "11440", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE,LESION,0.6-1.0 CM", "code_information": [ { "code": "11441", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE,LESION,1.1=2.0 CM", "code_information": [ { "code": "11442", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION,2.1-3 CM", "code_information": [ { "code": "11443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION,3.1-4 CM", "code_information": [ { "code": "11444", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,MAL LESION ARMS\u003c.5", "code_information": [ { "code": "11600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION 0.6-1 CM", "code_information": [ { "code": "11601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE LESION 1.1-2 CM", "code_information": [ { "code": "11602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE,LESION 3.1-4 CM", "code_information": [ { "code": "11604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISE MAL LESION \u003c.5 CM", "code_information": [ { "code": "11620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "INTERCOSTAL NERVE SINGLE", "code_information": [ { "code": "64420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "INJEC,ANESTH AGENT; NERVE", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE,LESION,.06-1 CM", "code_information": [ { "code": "11621", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11623", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11624", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISE LESION 1.1-2 CM", "code_information": [ { "code": "11622", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11626", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "EXCISE LESION \u003c.5 CM", "code_information": [ { "code": "11640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE MAL LES 0.6 -1.CM", "code_information": [ { "code": "11641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE MAL LESION 1.1-2", "code_information": [ { "code": "11642", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11643", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11644", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11646", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "INSERT TUNNEL CATH \u003e=5YRS", "code_information": [ { "code": "36558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "VENIPUNCTURE\u003c1 YR", "code_information": [ { "code": "36420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "VENIPUNCTURE, CUTDWN \u003e 1Y", "code_information": [ { "code": "36425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLS CARPOMETACARPAL DISLO", "code_information": [ { "code": "26670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion", "code_information": [ { "code": "36590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 299, "minimum": 299 } ] }, { "description": "DEBRIDE, NAILS,\u003c=5", "code_information": [ { "code": "11720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOSED TXT METACARP FRACT", "code_information": [ { "code": "26605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DEBRIDE NAILS \u003e6", "code_information": [ { "code": "11721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOSED TREATMENT OF DISLOCATED THUMB", "code_information": [ { "code": "26641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "AVUL,NAIL PLATE, EA ADD", "code_information": [ { "code": "11732", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CRYOTHERAPY, ACNE*", "code_information": [ { "code": "17340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLSD REDUCT MCP DISLOC WO", "code_information": [ { "code": "26700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLSD TXT DISTL PHALG FRAC", "code_information": [ { "code": "26750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "TX INTERPHAL JOINT DISLOC", "code_information": [ { "code": "26770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLSD REDUCT FINGER DISLOC", "code_information": [ { "code": "26775", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "DEST LES LID MARGN TO 1CM", "code_information": [ { "code": "67850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "REPAIR WOUND 12.6-20.0 CM", "code_information": [ { "code": "12005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR WOUND 20.1-30 CM", "code_information": [ { "code": "12006", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR WOUND \u003e30 CM", "code_information": [ { "code": "12007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "I\u0026D EXTERNAL EAR", "code_information": [ { "code": "69000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "I\u0026D PILONIDAL CYST COMP", "code_information": [ { "code": "10081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "REPAIR SIMPLE 12.6-20 CM", "code_information": [ { "code": "12016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR SIMPLE 20.1-30 CM", "code_information": [ { "code": "12017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "AMPUTATION, FINGER/THUMB", "code_information": [ { "code": "26951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "REPAIR SIMPLE \u003e30 CM", "code_information": [ { "code": "12018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE 7.6-12.5 CM", "code_information": [ { "code": "12034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE \u003e30.0 CM", "code_information": [ { "code": "12037", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE 12.6-20 CM", "code_information": [ { "code": "12045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE \u003e30 CM", "code_information": [ { "code": "12047", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE 7.6-12.5", "code_information": [ { "code": "12054", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE 12.6-20 CM", "code_information": [ { "code": "12055", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE 20.1-30 CM", "code_information": [ { "code": "12056", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "LAYER CLOSURE \u003e30 CM", "code_information": [ { "code": "12057", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR,COMPLEX 1.1-2.5 CM", "code_information": [ { "code": "13100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "REPAIR,COMPLEX 2.6-7.5 CM", "code_information": [ { "code": "13101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "REPAIR COMP.ARM 1.1-2.5", "code_information": [ { "code": "13120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE. PROUD FLESH)", "code_information": [ { "code": "17250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 42, "minimum": 42 } ] }, { "description": "CLS TXT POST HIP ARTHRO", "code_information": [ { "code": "27265", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DESTRUCT,1 LESION BENIGN", "code_information": [ { "code": "17000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR COMPLEX 1.1-2.5 CM", "code_information": [ { "code": "13151", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "DESTRUCT, LESION,2-14 EA", "code_information": [ { "code": "17003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REPAIR COMPLEX 2.6-7.5 CM", "code_information": [ { "code": "13152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "CLOSURE WOUND/EXTEN/COMPL", "code_information": [ { "code": "13160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "DESTRUCT LESIONS \u003e15", "code_information": [ { "code": "17004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DESTRUCT WARTS, 1-14", "code_information": [ { "code": "17110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "DESTRUCT MAL LESION\u003c.5CM", "code_information": [ { "code": "17280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOSED TXT PATEL DISLOC", "code_information": [ { "code": "27562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "INJECT,TRIGGER POINTS", "code_information": [ { "code": "20550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "INJECT SM JOINT", "code_information": [ { "code": "20600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "INJECT,INTERMEDIATE JNT", "code_information": [ { "code": "20605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "INJECT MAJOR JOINT", "code_information": [ { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "INCISION,DEEP ABCESS", "code_information": [ { "code": "27301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1164, "minimum": 1164 } ] }, { "description": "EXPL WOUND,ABD/FLANK/BACK", "code_information": [ { "code": "20102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "REMOVAL OF F/B SIMPLE", "code_information": [ { "code": "20520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "APPLY CAST, LONG ARM", "code_information": [ { "code": "29065", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "APPLY CAST, SHORT ARM", "code_information": [ { "code": "29075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "APPLY SPLINT, FINGER", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "APPLY CAST, LONG LEG", "code_information": [ { "code": "29345", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOSED TXT ANKLE DISLOC", "code_information": [ { "code": "27840", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "ANKLE STRAPPING", "code_information": [ { "code": "29540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "APPLY CAST, SHORT LEG", "code_information": [ { "code": "29405", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVE F/B NASAL*", "code_information": [ { "code": "30300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVE, F/B MOUTH", "code_information": [ { "code": "40804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "BIOPSY,VULVA/PERINEUM", "code_information": [ { "code": "56605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "ENDOMETRIAL BIOPSY", "code_information": [ { "code": "58100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVAL OF F.B. EXT EYE", "code_information": [ { "code": "65205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVE F/B EYELID", "code_information": [ { "code": "67938", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVE FOREIGN BODY EAR", "code_information": [ { "code": "69200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "REMOVE IMPACTED CERUMEN", "code_information": [ { "code": "69210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXCIS LESION TENDON FOOT", "code_information": [ { "code": "28090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "REMOVAL, F/B FOOT, SUBCUT", "code_information": [ { "code": "28190", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 833, "minimum": 833 } ] }, { "description": "REMOVAL OF IUD", "code_information": [ { "code": "58301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CLOSED TREATMENT OF METATARSAL FRACTURE W/O MANIPULATION, EACH", "code_information": [ { "code": "28470", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION", "code_information": [ { "code": "28490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH", "code_information": [ { "code": "28515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAT GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH", "code_information": [ { "code": "28525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 243, "minimum": 243 } ] }, { "description": "NV SPECIFIC W/C CODE FIRST HOUR FOR USE OF EMERGENCY FACILITY", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NV SPECIFIC W/C CODE EACH ADDITIONAL HOUR OR FRACTION THEREOF FOR USE OF EMERGENCY FACILITY", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TXT WOUND DEHIS SIMPLE", "code_information": [ { "code": "12020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "APPLY CAST, FINGER", "code_information": [ { "code": "29086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "MODERATE SEDATION SERVICES, EA ADDL 15 MIN INTRA-SERVICE TIME", "code_information": [ { "code": "99152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "VAGINAL DELIVERY ONLY", "code_information": [ { "code": "59409", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1739, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1594, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1830, "minimum": 1830 } ] }, { "description": "CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT, ALL PLACES OF SERVICE", "code_information": [ { "code": "P9612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "TELEHEALTH ORIGINATING SITE FEE", "code_information": [ { "code": "Q3014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "EXCIS PILONIDL CYST/SINUS", "code_information": [ { "code": "10021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 247, "minimum": 247 } ] }, { "description": "EXPLORE PENETRATING WOUND", "code_information": [ { "code": "20103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 422, "minimum": 422 } ] }, { "description": "EPSDT IMMUN ADMIN, 1 VACC", "code_information": [ { "code": "90471", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "I\u0026D PERIANAL ABSCESS SUPR", "code_information": [ { "code": "46050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 255, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 274, "minimum": 274 } ] }, { "description": "INJECT, CARPAL TUNNEL", "code_information": [ { "code": "20526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "INJECT, SINGLE TENDON", "code_information": [ { "code": "20551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "INJ,\u003e=1 TRIG PT,\u003e=3 MUSCL", "code_information": [ { "code": "20553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 109, "minimum": 109 } ] }, { "description": "REMOVAL IMPLANT, SUPERFI", "code_information": [ { "code": "20670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "DEBRIDE INC REMOV FOREIGN", "code_information": [ { "code": "11012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 797, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 797, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 797, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 780, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 731, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 839, "minimum": 839 } ] }, { "description": "DEBRIDE ECZEM SKIN ADD\u0027L", "code_information": [ { "code": "11001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "INTUBATION, GASTRIC", "code_information": [ { "code": "43753", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "SUBUNGUAL HEMATOMA", "code_information": [ { "code": "11740", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "REPAIR LACER \u003c=2.5 MOUTH", "code_information": [ { "code": "41250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "SHAVE BX TRUNK \u003c0.5CM", "code_information": [ { "code": "11300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "SHAVE BX TRUNK 0.6-1.00CM", "code_information": [ { "code": "11301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "SHAVE BX TRUNK 1.1-2.0CM", "code_information": [ { "code": "11302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "SHAVE EPIDERM LESION .5CM", "code_information": [ { "code": "11310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "SURG PREP EXCIS 100CM 1%", "code_information": [ { "code": "15002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 359, "minimum": 359 } ] }, { "description": "SPLIT GRAFT 1ST 100 SQ CM", "code_information": [ { "code": "15100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 811, "minimum": 811 } ] }, { "description": "FULL THCK GRAFT TRNK\u003c20CM", "code_information": [ { "code": "15200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 803, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 752, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 863, "minimum": 863 } ] }, { "description": "DRESS CHG UNDER ANESTHES", "code_information": [ { "code": "15852", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "I \u0026 D OF BURNS SAMLL", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 125, "minimum": 125 } ] }, { "description": "BLADDER INSTILLATION", "code_information": [ { "code": "51720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 213, "minimum": 213 } ] }, { "description": "EXC PILONIDAL CYST XTENSV", "code_information": [ { "code": "11771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 790, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 739, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 849, "minimum": 849 } ] }, { "description": "EXCISION TUMOR BACK/FLANK", "code_information": [ { "code": "21930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 529, "minimum": 529 } ] }, { "description": "TXT WOUND DEHIS SIMPLE", "code_information": [ { "code": "12020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 359, "minimum": 359 } ] }, { "description": "LAYER CLOSURE, 20.1-30CM", "code_information": [ { "code": "12036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 431, "minimum": 431 } ] }, { "description": "TRIGGER POINT SINGLE OR M", "code_information": [ { "code": "20552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "ASPIR/INJEC GANGLION CYST", "code_information": [ { "code": "20612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "SIALOLITHOTOMY UNCOMPLICA", "code_information": [ { "code": "42330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 316, "minimum": 316 } ] }, { "description": "INTRO NEEDLE/CATH VEIN *", "code_information": [ { "code": "36000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 19, "minimum": 19 } ] }, { "description": "CLOSED TREATMENT OF CLAVICULAR FRACTURE W/O MANIPULATION", "code_information": [ { "code": "23500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "THORACENTESIS ASPIRATION", "code_information": [ { "code": "32554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "T/X ELBOW DISLOCAT W/O AN", "code_information": [ { "code": "24600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 548, "minimum": 548 } ] }, { "description": "CLOSED TREAT RADIAL HEAD", "code_information": [ { "code": "24640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "RADIAL HEAD W/O MAL", "code_information": [ { "code": "24650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "EXCISION GANGLION CYST WR", "code_information": [ { "code": "25111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "CLOSED TX OF RADIAL", "code_information": [ { "code": "25565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 679, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 730, "minimum": 730 } ] }, { "description": "DRAIN,FINGER ABCESS,SIMP*", "code_information": [ { "code": "26010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "EXC LES OF TENDON SHEATH", "code_information": [ { "code": "26160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "CLOSED T/X METACARPAL FRA", "code_information": [ { "code": "26600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 425, "minimum": 425 } ] }, { "description": "OPEN TXT DIST PHALANG FX", "code_information": [ { "code": "26765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 565, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 530, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 608, "minimum": 608 } ] }, { "description": "CLOSED TREAT PATELLAR DIS", "code_information": [ { "code": "27560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 452, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 486, "minimum": 486 } ] }, { "description": "CTRL NASOPHARYNG HEMORRHA", "code_information": [ { "code": "42970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 764, "minimum": 764 } ] }, { "description": "DRAIN ABCESS NASAL INTERA", "code_information": [ { "code": "30000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "TUBE THORACOSTOMY", "code_information": [ { "code": "32551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 353, "minimum": 353 } ] }, { "description": "STRSS TST-INTERP \u0026 REPORT", "code_information": [ { "code": "93018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "REPAIR COMP.\u003c=5CM, EA ADD", "code_information": [ { "code": "13122", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "REPAIR,COMPLX,ADDL,\u003c=5CM", "code_information": [ { "code": "13133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "REPAIR CMPLX EA ADDL\u003c=5CM", "code_information": [ { "code": "13153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 255, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 274, "minimum": 274 } ] }, { "description": "HOLTER PHYS REVIEW/INTERP", "code_information": [ { "code": "93227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "THROMBOLYSIS,IV", "code_information": [ { "code": "92977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 634, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 634, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 634, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 620, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 581, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 667, "minimum": 667 } ] }, { "description": "VENIPUNCTURE\u003c3YR FEMORAL", "code_information": [ { "code": "36400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "CLOS TX SHLDR DISLOC,ANES", "code_information": [ { "code": "23655", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 548, "minimum": 548 } ] }, { "description": "DILATE FEMALE URETH, INIT", "code_information": [ { "code": "53660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "DILATE FEMALE URETH SUBSQ", "code_information": [ { "code": "53661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION", "code_information": [ { "code": "36680", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "GASTRIC INTUBATION \u0026 ASPIRATION", "code_information": [ { "code": "43753", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "LIGATION VARICOSE VEIN", "code_information": [ { "code": "37785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "CIRCUMCISION \u003e28 DAYS OLD", "code_information": [ { "code": "54161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 491, "minimum": 491 } ] }, { "description": "COLONSCOPY THROUGH STOMA", "code_information": [ { "code": "44388", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 861, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 926, "minimum": 926 } ] }, { "description": "Injection, anesthetic agent; trigeminal nerve, any division or branch", "code_information": [ { "code": "64400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 147, "minimum": 147 } ] }, { "description": "INJ, ANES AGENT ILIO NRVS", "code_information": [ { "code": "64425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "I \u0026 D TRANSRECTAL ABCESS", "code_information": [ { "code": "45005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "I\u0026D DEEP SUPRALEVATOR ABS", "code_information": [ { "code": "45020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 416, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 478, "minimum": 478 } ] }, { "description": "EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS", "code_information": [ { "code": "46230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 499, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 499, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 499, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 525, "minimum": 525 } ] }, { "description": "ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)", "code_information": [ { "code": "46600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 66, "minimum": 66 } ] }, { "description": "CLOSED TX ULNAR FRACTURE", "code_information": [ { "code": "24670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "DRAIN-SCROTAL WALL ABCESS", "code_information": [ { "code": "55100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 548, "minimum": 548 } ] }, { "description": "I\u0026D BARTHOLIN GLAND ABSCE", "code_information": [ { "code": "56420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "HOSP VISIT,SUBSEQ, LOW", "code_information": [ { "code": "99231", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "ADM/DC SAME DAY-HIGH IP", "code_information": [ { "code": "99236", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 481, "minimum": 481 } ] }, { "description": "SNF VISIT,INIT,LOW", "code_information": [ { "code": "99304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "MEATOTOMY, CUTTING MEATUS", "code_information": [ { "code": "53020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 331, "minimum": 331 } ] }, { "description": "SNF VISIT,INIT,MOD", "code_information": [ { "code": "99305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "SNF VISIT,INIT,HIGH", "code_information": [ { "code": "99306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "SNF VISIT,SUBSEQ,LOW", "code_information": [ { "code": "99307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "SNF VISIT,SUBSEQ,MOD", "code_information": [ { "code": "99308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 72, "minimum": 72 } ] }, { "description": "SWG SUBSEQ, HIGH, SKLD", "code_information": [ { "code": "99309", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "SNF, DISCHARGE 30 MINS.", "code_information": [ { "code": "99315", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "SNF, DISCHARGE \u003e 30 MINS.", "code_information": [ { "code": "99316", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 142, "minimum": 142 } ] }, { "description": "HOSP CARE,ADMIT,INIT,LOW", "code_information": [ { "code": "99221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 240, "minimum": 240 } ] }, { "description": "BLOOD,OCCULT", "code_information": [ { "code": "82270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "INJECT, SUBQ OR INTRAMUSC", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 9, "minimum": 9 } ] }, { "description": "REMOVE RECTAL OBSTRUCTION", "code_information": [ { "code": "45915", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "CURETTAGE POSTPARTUM", "code_information": [ { "code": "59160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "THORACENTESIS,INT/OR SUB*", "code_information": [ { "code": "32554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 240, "minimum": 240 } ] }, { "description": "ASPIRATION OF ABCESS *", "code_information": [ { "code": "10160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "I\u0026D COMPLEX,WOUND INF", "code_information": [ { "code": "10180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 264, "minimum": 264 } ] }, { "description": "REMOVE F/B SUBQ COMP", "code_information": [ { "code": "10121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "I\u0026D HEMOTOMA,FLUID RET *", "code_information": [ { "code": "10140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "DEBRIDEMENT 10% BODY SURF", "code_information": [ { "code": "11000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "DEBRIDE, FULL THICKNESS", "code_information": [ { "code": "16030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "DEBRIDE, SUBQ TISSUE", "code_information": [ { "code": "11042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "REMOVE F/B MOUTH COMPLEX", "code_information": [ { "code": "40805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "REMOVE, SKIN TAGS TO 15*", "code_information": [ { "code": "11200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "EXCISE LESION \u003c=0.5CM", "code_information": [ { "code": "11400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "EXCISE, LESION, 0.6-1.0CM", "code_information": [ { "code": "11401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 248, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 267, "minimum": 267 } ] }, { "description": "EXCISE, LESION 1.1-2.0 CM", "code_information": [ { "code": "11402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "EXCISE, LESION, 2.1-3.0CM", "code_information": [ { "code": "11403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXCISE,LESION 3.1-4.0CM", "code_information": [ { "code": "11404", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 298, "minimum": 298 } ] }, { "description": "EXCISE,LESION,\u003e4.0CM", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 394, "minimum": 394 } ] }, { "description": "EXCISE, LESION \u003c=0.5CM", "code_information": [ { "code": "11420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11421", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 284, "minimum": 284 } ] }, { "description": "EXCISE,LESION,1.1-2.0CM", "code_information": [ { "code": "11422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 313, "minimum": 313 } ] }, { "description": "EXCISE,LESION,2.1-3 CM", "code_information": [ { "code": "11423", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "EXCISE,LESION,3.1-4 CM", "code_information": [ { "code": "11424", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 332, "minimum": 332 } ] }, { "description": "REMOVE FB CONJUNCT EMBED", "code_information": [ { "code": "65210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "SPINAL PUNCTURE DIAGNOSTI", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "EXCISE,LESION,4.0 CM", "code_information": [ { "code": "11426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 471, "minimum": 471 } ] }, { "description": "EXCISE,LESION,\u003c=.05CM", "code_information": [ { "code": "11440", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "EXCISE,LESION,0.6-1.0 CM", "code_information": [ { "code": "11441", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "EXCISE,LESION,1.1=2.0 CM", "code_information": [ { "code": "11442", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "EXCISE,LESION,2.1-3 CM", "code_information": [ { "code": "11443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "EXCISE,LESION,3.1-4 CM", "code_information": [ { "code": "11444", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 443, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 509, "minimum": 509 } ] }, { "description": "EXCISE,LESION,\u003e4 CM", "code_information": [ { "code": "11446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 524, "minimum": 524 } ] }, { "description": "EXCISE,MAL LESION ARMS\u003c.5", "code_information": [ { "code": "11600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "CHEMOTHERAPY ADMIN SUBCUT", "code_information": [ { "code": "96402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "EXCISE,LESION 0.6-1 CM", "code_information": [ { "code": "11601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "EXCISE LESION 1.1-2 CM", "code_information": [ { "code": "11602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 443, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 509, "minimum": 509 } ] }, { "description": "EXCISE,LESION 3.1-4 CM", "code_information": [ { "code": "11604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 390, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 390, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 390, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 410, "minimum": 410 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 533, "minimum": 533 } ] }, { "description": "EXCISE MAL LESION \u003c.5 CM", "code_information": [ { "code": "11620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "INTERCOSTAL NERVE SINGLE", "code_information": [ { "code": "64420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 96, "minimum": 96 } ] }, { "description": "INJEC,ANESTH AGENT; NERVE", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "EXCISE,LESION,.06-1 CM", "code_information": [ { "code": "11621", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11623", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 415, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 415, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 415, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 406, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 437, "minimum": 437 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11624", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 524, "minimum": 524 } ] }, { "description": "EXCISE LESION 1.1-2 CM", "code_information": [ { "code": "11622", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11626", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 582, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 626, "minimum": 626 } ] }, { "description": "UMBIL VEIN CATH, NEWBORN", "code_information": [ { "code": "36510", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 118, "minimum": 118 } ] }, { "description": "EXCISE LESION \u003c.5 CM", "code_information": [ { "code": "11640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 248, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 267, "minimum": 267 } ] }, { "description": "EXCISE MAL LES 0.6 -1.CM", "code_information": [ { "code": "11641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 398, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 428, "minimum": 428 } ] }, { "description": "EXCISE MAL LESION 1.1-2", "code_information": [ { "code": "11642", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 499, "minimum": 499 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11643", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11644", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 594, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 557, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 639, "minimum": 639 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11646", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 764, "minimum": 764 } ] }, { "description": "PERITONEOCENTESIS,ABD/PE*", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 215, "minimum": 215 } ] }, { "description": "INSERT TUNNEL CATH \u003e=5YRS", "code_information": [ { "code": "36558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "VENIPUNCTURE\u003c1 YR", "code_information": [ { "code": "36420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "IV START BY PROVIDER *", "code_information": [ { "code": "36000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 19, "minimum": 19 } ] }, { "description": "VENIPUNCTURE, CUTDWN \u003e 1Y", "code_information": [ { "code": "36425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "CLS CARPOMETACARPAL DISLO", "code_information": [ { "code": "26670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 471, "minimum": 471 } ] }, { "description": "Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion", "code_information": [ { "code": "36590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 299, "minimum": 299 } ] }, { "description": "TEMP TRANSCUTANEOUS PACIN", "code_information": [ { "code": "92953", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 45, "minimum": 45 } ] }, { "description": "DEBRIDE, NAILS,\u003c=5", "code_information": [ { "code": "11720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "CLOSED TXT METACARP FRACT", "code_information": [ { "code": "26605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 379, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 435, "minimum": 435 } ] }, { "description": "DEBRIDE NAILS \u003e6", "code_information": [ { "code": "11721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 86, "minimum": 86 } ] }, { "description": "CLOSED TREATMENT OF DISLOCATED THUMB", "code_information": [ { "code": "26641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "AVUL, NAIL PLATE, 1 SIMP*", "code_information": [ { "code": "11730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "AVUL,NAIL PLATE, EA ADD", "code_information": [ { "code": "11732", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "CRYOTHERAPY, ACNE*", "code_information": [ { "code": "17340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "CLSD REDUCT MCP DISLOC WO", "code_information": [ { "code": "26700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 495, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 463, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 532, "minimum": 532 } ] }, { "description": "EXCISE,NAIL PART/COMPLETE", "code_information": [ { "code": "11750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 394, "minimum": 394 } ] }, { "description": "CLSD TXT DISTL PHALG FRAC", "code_information": [ { "code": "26750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 281, "minimum": 281 } ] }, { "description": "TX INTERPHAL JOINT DISLOC", "code_information": [ { "code": "26770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 458, "minimum": 458 } ] }, { "description": "CLSD REDUCT FINGER DISLOC", "code_information": [ { "code": "26775", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 576, "minimum": 576 } ] }, { "description": "DEST LES LID MARGN TO 1CM", "code_information": [ { "code": "67850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 272, "minimum": 272 } ] }, { "description": "I\u0026D PILONIDAL CYST *", "code_information": [ { "code": "10080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "REPAIR WOUND 12.6-20.0 CM", "code_information": [ { "code": "12005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 324, "minimum": 324 } ] }, { "description": "REPAIR WOUND 20.1-30 CM", "code_information": [ { "code": "12006", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "REPAIR WOUND \u003e30 CM", "code_information": [ { "code": "12007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "I\u0026D EXTERNAL EAR", "code_information": [ { "code": "69000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "I\u0026D PILONIDAL CYST COMP", "code_information": [ { "code": "10081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 303, "minimum": 303 } ] }, { "description": "REPAIR SIMPLE 12.6-20 CM", "code_information": [ { "code": "12016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 342, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 368, "minimum": 368 } ] }, { "description": "REPAIR SIMPLE 20.1-30 CM", "code_information": [ { "code": "12017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 416, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 478, "minimum": 478 } ] }, { "description": "AMPUTATION, FINGER/THUMB", "code_information": [ { "code": "26951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 825, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 825, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 825, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 756, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 868, "minimum": 868 } ] }, { "description": "REPAIR SIMPLE \u003e30 CM", "code_information": [ { "code": "12018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 571, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 535, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 614, "minimum": 614 } ] }, { "description": "LAYER CLOSURE \u003c2.5 CM *", "code_information": [ { "code": "12031", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "LAYER CLOSURE 7.6-12.5 CM", "code_information": [ { "code": "12034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 382, "minimum": 382 } ] }, { "description": "LAYER CLOSURE 12.6-20 CM", "code_information": [ { "code": "12035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 326, "minimum": 326 } ] }, { "description": "LAYER CLOSURE \u003e30.0 CM", "code_information": [ { "code": "12037", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 417, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 479, "minimum": 479 } ] }, { "description": "LAYER CLOSURE 7.6-12.5CM", "code_information": [ { "code": "12044", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 268, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 288, "minimum": 288 } ] }, { "description": "LAYER CLOSURE 12.6-20 CM", "code_information": [ { "code": "12045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 351, "minimum": 351 } ] }, { "description": "LAYER CLOSURE 20.1-30 CM", "code_information": [ { "code": "12046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 378, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 434, "minimum": 434 } ] }, { "description": "LAYER CLOSURE 2.6-5.0 CM", "code_information": [ { "code": "12052", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "LAYER CLOSURE \u003e30 CM", "code_information": [ { "code": "12047", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 458, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 526, "minimum": 526 } ] }, { "description": "LAYER CLOSURE, 5.1-7.5 CM", "code_information": [ { "code": "12053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 294, "minimum": 294 } ] }, { "description": "LAYER CLOSURE 7.6-12.5", "code_information": [ { "code": "12054", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 440, "minimum": 440 } ] }, { "description": "LAYER CLOSURE 12.6-20 CM", "code_information": [ { "code": "12055", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 429, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 402, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 461, "minimum": 461 } ] }, { "description": "LAYER CLOSURE 20.1-30 CM", "code_information": [ { "code": "12056", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 572, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 572, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 572, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 560, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 524, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 602, "minimum": 602 } ] }, { "description": "LAYER CLOSURE \u003e30 CM", "code_information": [ { "code": "12057", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 657, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 657, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 657, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 644, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 603, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 692, "minimum": 692 } ] }, { "description": "REPAIR,COMPLEX 1.1-2.5 CM", "code_information": [ { "code": "13100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 440, "minimum": 440 } ] }, { "description": "REPAIR,COMPLEX 2.6-7.5 CM", "code_information": [ { "code": "13101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 320, "minimum": 320 } ] }, { "description": "REPAIR COMP.ARM 1.1-2.5", "code_information": [ { "code": "13120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 257, "minimum": 257 } ] }, { "description": "HOSP VISIT,SUB,LOW-VONFEL", "code_information": [ { "code": "99231", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "HOSP VISIT,SUB,MOD-VONFEL", "code_information": [ { "code": "99232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "HOSP VISIT,SUB,HIGH-VONFE", "code_information": [ { "code": "99233", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE. PROUD FLESH)", "code_information": [ { "code": "17250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "REPAIR COMP,CHIN 1.1-2.5", "code_information": [ { "code": "13131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 269, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 309, "minimum": 309 } ] }, { "description": "CLS TXT POST HIP ARTHRO", "code_information": [ { "code": "27265", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "DESTRUCT,1 LESION BENIGN*", "code_information": [ { "code": "17000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "REPAIR COMPLEX 1.1-2.5 CM", "code_information": [ { "code": "13151", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 458, "minimum": 458 } ] }, { "description": "DESTRUCT, LESION,2-14 EA", "code_information": [ { "code": "17003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "REPAIR COMPLEX 2.6-7.5 CM", "code_information": [ { "code": "13152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 676, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 633, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 727, "minimum": 727 } ] }, { "description": "CLOSURE WOUND/EXTEN/COMPL", "code_information": [ { "code": "13160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 819, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 767, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 881, "minimum": 881 } ] }, { "description": "DESTRUCT LESIONS \u003e15", "code_information": [ { "code": "17004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "DESTRUCT WARTS, 1-14 *", "code_information": [ { "code": "17110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "DESTRUCT WARTS\u003e15", "code_information": [ { "code": "17111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "DESTRUCT MAL LESION\u003c.5CM*", "code_information": [ { "code": "17280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "CLOSED TXT PATEL DISLOC", "code_information": [ { "code": "27562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1029, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 963, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1106, "minimum": 1106 } ] }, { "description": "DEBRIDEMENT, OPEN WOUND, FIRST 20 SQ CM OR LESS", "code_information": [ { "code": "97597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "INJECT,TRIGGER POINTS *", "code_information": [ { "code": "20550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "INJECT SM JOINT *", "code_information": [ { "code": "20600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "NEG PRESS WOUND TXT \u003c50CM", "code_information": [ { "code": "97605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "INJECT,INTERMEDIATE JNT *", "code_information": [ { "code": "20605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "INJECT MAJOR JOINT *", "code_information": [ { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "INCISION,DEEP ABCESS", "code_information": [ { "code": "27301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 792, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 852, "minimum": 852 } ] }, { "description": "EXPL WOUND,ABD/FLANK/BACK", "code_information": [ { "code": "20102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 369, "minimum": 369 } ] }, { "description": "REMOVAL OF F/B SIMPLE*", "code_information": [ { "code": "20520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 256, "minimum": 256 } ] }, { "description": "APPLY CAST, LONG ARM", "code_information": [ { "code": "29065", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "APPLY CAST, SHORT ARM", "code_information": [ { "code": "29075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "APPLY SPLINT, FINGER", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "APPLY CAST, LONG LEG", "code_information": [ { "code": "29345", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 280, "minimum": 280 } ] }, { "description": "CLOSED TXT ANKLE DISLOC", "code_information": [ { "code": "27840", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "ANKLE STRAPPING", "code_information": [ { "code": "29540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "APPLY CAST, SHORT LEG", "code_information": [ { "code": "29405", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "REMOVE F/B NASAL*", "code_information": [ { "code": "30300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "REMOVE, F/B MOUTH *", "code_information": [ { "code": "40804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 169, "minimum": 169 } ] }, { "description": "APPLY CATH, URETHRA SIMP*", "code_information": [ { "code": "0981", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "BIOPSY,VULVA/PERINEUM *", "code_information": [ { "code": "56605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 163, "minimum": 163 } ] }, { "description": "ENDOMETRIAL BIOPSY *", "code_information": [ { "code": "58100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "REMOVAL OF F.B. EXT EYE*", "code_information": [ { "code": "65205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "SURGERY ASST CARPAL TUN", "code_information": [ { "code": "64721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 142, "minimum": 142 } ] }, { "description": "SURG ASST MENISCECTOMY", "code_information": [ { "code": "29881", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 298, "minimum": 298 } ] }, { "description": "REMOVE F/B EYELID", "code_information": [ { "code": "67938", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "REMOVE FOREIGN BODY EAR", "code_information": [ { "code": "69200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "MANP,1-2 BODY REGIONS", "code_information": [ { "code": "98925", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "MANIP, 3-4 BODY REGIONS", "code_information": [ { "code": "98926", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "MANIP 5-6 BODY REGIONS", "code_information": [ { "code": "98927", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "MANIP 7-8 BODY REGIONS", "code_information": [ { "code": "98928", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "EXCIS LESION TENDON FOOT", "code_information": [ { "code": "28090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 470, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 505, "minimum": 505 } ] }, { "description": "INCISION EXT HEMORRHOID", "code_information": [ { "code": "46083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 216, "minimum": 216 } ] }, { "description": "REMOVAL, F/B FOOT, SUBCUT", "code_information": [ { "code": "28190", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 328, "minimum": 328 } ] }, { "description": "REMOVAL OF IUD", "code_information": [ { "code": "58301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "CLOSED TREATMENT OF METATARSAL FRACTURE W/O MANIPULATION, EACH", "code_information": [ { "code": "28470", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 162, "minimum": 162 } ] }, { "description": "CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION", "code_information": [ { "code": "28490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 230, "minimum": 230 } ] }, { "description": "CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH", "code_information": [ { "code": "28515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAT GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH", "code_information": [ { "code": "28525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 472, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 472, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 472, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 497, "minimum": 497 } ] }, { "description": "POSTOPERATIVE FOLLOW-UP VISIT, NORMALLY INCLUDED IN THE SURGICAL PACKAGE", "code_information": [ { "code": "99024", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FETAL NON-STRESS TEST", "code_information": [ { "code": "59025,26", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "PERITONEOCENTESIS SUBSEQ", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "APPLY CAST, FINGER", "code_information": [ { "code": "29086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "MODERARE SEDATION SERVICES, \u003e 5YO, FIRST 30 MINUTES INTRA-SERVICE TIME", "code_information": [ { "code": "99151", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "MODERATE SEDATION SERVICES, EA ADDL 15 MIN INTRA-SERVICE TIME", "code_information": [ { "code": "99152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "IP CONSULT LEVEL 1", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 64, "minimum": 64 } ] }, { "description": "IP CONSULT LEVEL 2", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "IP CONSULT LEVEL 3", "code_information": [ { "code": "99221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "IP CONSULT LEVEL 5", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 345, "minimum": 345 } ] }, { "description": "VAGINAL DELIVERY ONLY", "code_information": [ { "code": "59409", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1722, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1613, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1852, "minimum": 1852 } ] }, { "description": "VAG DELIV W/POSTPART CARE", "code_information": [ { "code": "59410", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1963, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1963, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1963, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1921, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1799, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2066, "minimum": 2066 } ] }, { "description": "DELIVER PLACENTA SEPARATE", "code_information": [ { "code": "59414", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 614, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 575, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 660, "minimum": 660 } ] }, { "description": "ANTEPARTUM CARE ONLY;4-6", "code_information": [ { "code": "59425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 588, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 675, "minimum": 675 } ] }, { "description": "ANTEPARTUM CARE;7 OR MORE", "code_information": [ { "code": "59426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1039, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1039, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1039, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1017, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 953, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1094, "minimum": 1094 } ] }, { "description": "POSTPARTUM CARE ONLY", "code_information": [ { "code": "59430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 235, "minimum": 235 } ] }, { "description": "NEWBORN EXAM, HOSP CARE", "code_information": [ { "code": "99460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "NEWBORN EXAM, SUBSEQ HOSP", "code_information": [ { "code": "99462", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "NEWBORN RESUSCITATION", "code_information": [ { "code": "99465", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 321, "minimum": 321 } ] }, { "description": "PROLONGED SERVICE", "code_information": [ { "code": "99358", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "PHYSICIAN STANDBY", "code_information": [ { "code": "99360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE", "code_information": [ { "code": "45385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE", "code_information": [ { "code": "45380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS (2NDARY)", "code_information": [ { "code": "45384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES", "code_information": [ { "code": "43244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE", "code_information": [ { "code": "43239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE", "code_information": [ { "code": "43248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "COLONOSCOPY, FLEXIBLE, WITH BAND LIGATION (HEMORRHOIDS)", "code_information": [ { "code": "45398", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 772, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 830, "minimum": 830 } ] }, { "description": "ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS", "code_information": [ { "code": "43249", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE", "code_information": [ { "code": "43251", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "ESOPHAGOSCOPY", "code_information": [ { "code": "43200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 437, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 437, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 437, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 460, "minimum": 460 } ] }, { "description": "PEG TUBE PLACEMENT", "code_information": [ { "code": "43246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1023, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 958, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1100, "minimum": 1100 } ] }, { "description": "EGD WITH BLEED CONTROL", "code_information": [ { "code": "43255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 942, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 942, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 942, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 923, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 864, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 992, "minimum": 992 } ] }, { "description": "CLOSURE OF GASTROSTOMY, SURGICAL", "code_information": [ { "code": "43870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1297, "minimum": 1297 } ] }, { "description": "PEG TUBE REMOVAL", "code_information": [ { "code": "43500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "PERCUTANEOUS LIVER BIOPSY", "code_information": [ { "code": "47000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 990, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 990, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 990, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 969, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 908, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1042, "minimum": 1042 } ] }, { "description": "SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR BY SNARE TECHNIQUE", "code_information": [ { "code": "45338", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1023, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 958, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1100, "minimum": 1100 } ] }, { "description": "SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR BY SNARE TECHNIQUE SECONDARY", "code_information": [ { "code": "45338", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S)", "code_information": [ { "code": "45350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1131, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1059, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1216, "minimum": 1216 } ] }, { "description": "COLONSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION", "code_information": [ { "code": "45390", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1722, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1613, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 648, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1852, "minimum": 1852 } ] }, { "description": "COLONOSCOPY, FLEXIBLE, WITH BAND LIGATION (HEMORRHOIDS)", "code_information": [ { "code": "45398", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2279, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2135, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2451, "minimum": 2451 } ] }, { "description": "HEMORRHOIDECTOMY SIMPLE", "code_information": [ { "code": "46221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 715, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 715, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 715, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 700, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 753, "minimum": 753 } ] }, { "description": "LIGATION OF HEMORRHOIDS", "code_information": [ { "code": "46945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "EGD BALLN DIL", "code_information": [ { "code": "43249", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1347, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1261, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1448, "minimum": 1448 } ] }, { "description": "IP CONSULT LEVEL 2", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "PARACENTESIS", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "COLONOSCOPY", "code_information": [ { "code": "45378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1508, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1412, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 567, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 567, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 567, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 567, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 567, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1621, "minimum": 1621 } ] }, { "description": "SCREENING MCARE HIGH RISK", "code_information": [ { "code": "G0105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1513, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1737, "minimum": 1737 } ] }, { "description": "SCREENING MCARE AVG RISK", "code_information": [ { "code": "G0121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1513, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1737, "minimum": 1737 } ] }, { "description": "COLON W/POLYP REMOV SNARE", "code_information": [ { "code": "45385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1777, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1664, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1911, "minimum": 1911 } ] }, { "description": "COLONOSCOPY WITH BIOPSY", "code_information": [ { "code": "45380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1704, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1704, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1704, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1668, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1563, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1794, "minimum": 1794 } ] }, { "description": "COLON W/POLYP REMOV FORCP", "code_information": [ { "code": "45384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1777, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1664, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 669, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1911, "minimum": 1911 } ] }, { "description": "EGD W/BANDING VARICES", "code_information": [ { "code": "43244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1347, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1261, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1448, "minimum": 1448 } ] }, { "description": "EGD W/BIOPSY", "code_information": [ { "code": "43239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1077, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1009, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1158, "minimum": 1158 } ] }, { "description": "EGD DIL W/GUIDEWIRE", "code_information": [ { "code": "43248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1347, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1261, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1448, "minimum": 1448 } ] }, { "description": "FLEX SIG CANC SCRN-MCARE", "code_information": [ { "code": "G0104", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 861, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 926, "minimum": 926 } ] }, { "description": "FLEX SIG W/BIOPSY", "code_information": [ { "code": "45331", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1077, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1009, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1158, "minimum": 1158 } ] }, { "description": "EGD", "code_information": [ { "code": "43235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 936, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 936, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 936, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 916, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 985, "minimum": 985 } ] }, { "description": "FLEX SIGMOID-REMOVE POLYP", "code_information": [ { "code": "45333", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1048, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1048, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1048, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1026, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 961, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1103, "minimum": 1103 } ] }, { "description": "FLEX SIG", "code_information": [ { "code": "45330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 880, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 861, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 926, "minimum": 926 } ] }, { "description": "EGD WITH BLEED CONTROL", "code_information": [ { "code": "43255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 133, "minimum": 133 } ] }, { "description": "IP CONSULT LEVEL 4", "code_information": [ { "code": "99222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 637, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 637, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 637, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 624, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 584, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 671, "minimum": 671 } ] }, { "description": "IP CONSULT LEVEL 5", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 733, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 686, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 788, "minimum": 788 } ] }, { "description": "ALPHA-1-ANTITRYPSIN, RANDOM FECES", "code_information": [ { "code": "82103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "PHENYTOIN, FREE", "code_information": [ { "code": "80186", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 70, "minimum": 70 } ] }, { "description": "ALPHA-2-ANTIPLASMIN", "code_information": [ { "code": "85410", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 372, "minimum": 372 } ] }, { "description": "ALPRAZOLAM, SERUM", "code_information": [ { "code": "80346", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "AMINO ACID ANALYSIS, LC/MS, PLASMA", "code_information": [ { "code": "82139", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1513, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1737, "minimum": 1737 } ] }, { "description": "DELTA AMINOLEVULINIC ACID, 24-HOUR URINE", "code_information": [ { "code": "82135", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 313, "minimum": 313 } ] }, { "description": "ETHOSUXIMIDE", "code_information": [ { "code": "80168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "DELTA AMINOLEVULINIC ACID, RANDOM URINE", "code_information": [ { "code": "82135", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "AMIODARONE", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "AMOXICILLIN, HPLC", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 396, "minimum": 396 } ] }, { "description": "AMYLASE, PERITONEAL FLUID", "code_information": [ { "code": "82150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 108, "minimum": 108 } ] }, { "description": "HUNTINGTON DISEASE MUTATION ANALYSIS", "code_information": [ { "code": "81401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 962, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 962, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 962, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 942, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 882, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1013, "minimum": 1013 } ] }, { "description": "AMYLASE, PLEURAL FLUID", "code_information": [ { "code": "82150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "GLOMERULAR BASEMENT MEMBRANE ANTIBODY (IGG)", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 327, "minimum": 327 } ] }, { "description": "PARIETAL CELL ANTIBODY WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 189, "minimum": 189 } ] }, { "description": "ARSENIC, BLOOD", "code_information": [ { "code": "82175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 379, "minimum": 379 } ] }, { "description": "VAGINAL CULTURE", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "C1 Inhibitor, Functional", "code_information": [ { "code": "86161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 210, "minimum": 210 } ] }, { "description": "C1 Esterase Inhibitor, Protein", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 160, "minimum": 160 } ] }, { "description": "ANGIOTENSIN CONVERTING ENZYME (ACE)", "code_information": [ { "code": "82164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "ANTITHROMBIN III ACTIVITY WITH REFLEX TO ANTITHROMBIN III ANTIGEN", "code_information": [ { "code": "85301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "BETA-2-MICROGLOBULIN", "code_information": [ { "code": "82232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 320, "minimum": 320 } ] }, { "description": "BK VIRUS DNA, QUANTITATIVE REAL-TIME PCR, URINE", "code_information": [ { "code": "87799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 565, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 530, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 608, "minimum": 608 } ] }, { "description": "BK VIRUS DNA, QUANTITATIVE, REAL-TIME PCR, PLASMA", "code_information": [ { "code": "87799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 621, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 621, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 621, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 608, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 654, "minimum": 654 } ] }, { "description": "C. DIFFICILE TOXIN B, PCR", "code_information": [ { "code": "87493", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "Syphilis Antibody Cascading Reflex", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 210, "minimum": 210 } ] }, { "description": "CALCIUM, IONIZED", "code_information": [ { "code": "82330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "CARDIO CRP / HIGH SENSITIVITY", "code_information": [ { "code": "86141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 176, "minimum": 176 } ] }, { "description": "CARNITINE, LC/MS/MS", "code_information": [ { "code": "82379", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "CAROTENE", "code_information": [ { "code": "82380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "CEA (CARCINOEMBRYONIC ANTIGEN)", "code_information": [ { "code": "82378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 106, "minimum": 106 } ] }, { "description": "CAFFEINE", "code_information": [ { "code": "80155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "COMPLEMENT COMPONENT C4", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "COMPLEMENT, TOTAL (CH50)", "code_information": [ { "code": "86162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "C-REACTIVE PROTEIN (CRP)", "code_information": [ { "code": "86140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "DHEA SULFATE, IMMUNOASSAY", "code_information": [ { "code": "82627", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "ETHANOL (QUEST 110443)", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 349, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 375, "minimum": 375 } ] }, { "description": "EPSTEIN-BARR VIRUS EARLY ANTIGEN D ANTIBODY (IGG)", "code_information": [ { "code": "86663", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 313, "minimum": 313 } ] }, { "description": "ESTROGENS, FRACTIONATED, LC/MS/MS", "code_information": [ { "code": "82671", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 695, "minimum": 695 } ] }, { "description": "ESTRADIOL, ULTRASENSITIVE, LC/MS/MS", "code_information": [ { "code": "82670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "FRUCTOSAMINE", "code_information": [ { "code": "82985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "PHOSPHORUS, 24-HR URINE W/CREAT", "code_information": [ { "code": "84105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "GIARDIA ANTIGEN, EIA, STOOL", "code_information": [ { "code": "87329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "ARSENIC, RANDOM URINE 1", "code_information": [ { "code": "82175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 190, "minimum": 190 } ] }, { "description": "ARSENIC, RANDOM URINE 2", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 190, "minimum": 190 } ] }, { "description": "GRAM STAIN", "code_information": [ { "code": "87205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12, "minimum": 12 } ] }, { "description": "GLUCAGON", "code_information": [ { "code": "82943", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "LIVER CYTOSOL (LC-1) AUTOANTIBODIES", "code_information": [ { "code": "86376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "HEPATITIS C VIRUS RNA, QUANTITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 580, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 580, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 580, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 567, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 531, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 610, "minimum": 610 } ] }, { "description": "HALOPERIDOL", "code_information": [ { "code": "80173", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 332, "minimum": 332 } ] }, { "description": "HIV ANTIBODIES, HIV-1/2", "code_information": [ { "code": "86701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "DIHYDROTESTOSTERONE, LC/MS/MS", "code_information": [ { "code": "80327", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 324, "minimum": 324 } ] }, { "description": "HLA-B27 ANTIGEN", "code_information": [ { "code": "86812", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 468, "minimum": 468 } ] }, { "description": "TSI", "code_information": [ { "code": "84445", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 617, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 663, "minimum": 663 } ] }, { "description": "IGF-1, ELECTROCHEMILUMINESCENCE", "code_information": [ { "code": "84305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "IGE, TOTAL", "code_information": [ { "code": "82785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "IGG, SERUM", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "IGM, SERUM", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "MYCOBACTERIUM, CULTURE", "code_information": [ { "code": "0305", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "LAMOTRIGINE", "code_information": [ { "code": "80175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "MYELOMA PROFILE 1", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "CRYOGLOBULIN, QUALITATIVE ANALYSIS", "code_information": [ { "code": "82595", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "CYANIDE, BLOOD", "code_information": [ { "code": "82600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "LYSOZYME, MURAMIDASE", "code_information": [ { "code": "85549", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 103, "minimum": 103 } ] }, { "description": "MYELOMA PROFILE 2", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "LEAD, BLOOD", "code_information": [ { "code": "83655", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "MYELOMA PROFILE 3", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "MYELOMA PROFILE 4", "code_information": [ { "code": "82232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "LYME DISEASE, EIA W/RFL", "code_information": [ { "code": "86618", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "MAGNESIUM, RBC", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 211, "minimum": 211 } ] }, { "description": "NICOTINE AND COTININE, SERUM/PLASMA", "code_information": [ { "code": "80323", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 173, "minimum": 173 } ] }, { "description": "METHYL ALCOHOL, BLOOD", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "MITOCHONDRIAL ANTIBODY WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "NOROVIRUS RNA, RT-PCR", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 695, "minimum": 695 } ] }, { "description": "MYCOPHENOLIC ACID", "code_information": [ { "code": "80180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 350, "minimum": 350 } ] }, { "description": "OXYCODONE METAB, QT, SER", "code_information": [ { "code": "80361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "Cytology, Body Fluid", "code_information": [ { "code": "88312", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 270, "minimum": 270 } ] }, { "description": "RETICULIN ANTIBODY (IGA) WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "RETICULIN IGG SCREEN WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "FECAL FAT, TOTAL, QUANTITATIVE", "code_information": [ { "code": "82710", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 223, "minimum": 223 } ] }, { "description": "STONE ANALYSIS", "code_information": [ { "code": "82365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 206, "minimum": 206 } ] }, { "description": "STREP ANTIBODIES (ANTISTREPTOLYSIN-O)", "code_information": [ { "code": "86060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 42, "minimum": 42 } ] }, { "description": "STS (RPR) WITH REFLEX TO FTA", "code_information": [ { "code": "86592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "TISSUE TRANSGLUTAMINASE (TTG) ANTIBODY (IGG)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "VITAMIN D, 1,25-DIHYDROXY, LC/MS/MS", "code_information": [ { "code": "82652", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 695, "minimum": 695 } ] }, { "description": "OXAZEPAM", "code_information": [ { "code": "80346", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "Hepatitis C Viral RNA Genotype 1 NS3 Dru", "code_information": [ { "code": "87902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1048, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1048, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1048, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1026, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 961, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 386, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1103, "minimum": 1103 } ] }, { "description": "CYSTINE, 24-HOUR URINE", "code_information": [ { "code": "82131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 306, "minimum": 306 } ] }, { "description": "ALPRAZOLAM, QUANTITATIVE, URINE", "code_information": [ { "code": "80346", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "T 3 REVERSE, LC/MS/MS", "code_information": [ { "code": "84482", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 330, "minimum": 330 } ] }, { "description": "NICOTINE AND EXPANDED METABOLITES, LC/MS/MS, URINE", "code_information": [ { "code": "80323", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 65, "minimum": 65 } ] }, { "description": "Gluten IGG, serum (Allergen Gluten IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 109, "minimum": 109 } ] }, { "description": "TRYPSIN", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "METHOTREXATE", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "PHOSPHOLIPIDS", "code_information": [ { "code": "84311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 93, "minimum": 93 } ] }, { "description": "PROPERDIN FACTOR B", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "SIROLIMUS", "code_information": [ { "code": "80195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 379, "minimum": 379 } ] }, { "description": "BLASTOMYCOSIS URINE ANTIGEN", "code_information": [ { "code": "87449", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "OPIATES, QUANTITATIVE (SERUM)", "code_information": [ { "code": "80361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "DNASE-B ANTIBODY", "code_information": [ { "code": "86215", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "G6PD GLUCOSE-6-PHOSPHATE DEHYDROGENASE, QUANTITATIVE", "code_information": [ { "code": "82955", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 236, "minimum": 236 } ] }, { "description": "C-PEPTIDE", "code_information": [ { "code": "84681", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "COMPLEMENT COMPONENT C2", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "ADRENAL ANTIBODY SCREEN WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "COMPLEMENT COMPONENT C5", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "MAGNESIUM, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "SMA DIAGNOSTIC TEST", "code_information": [ { "code": "81329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 341, "minimum": 341 } ] }, { "description": "ROTAVIRUS ANTIGEN DETECTION", "code_information": [ { "code": "87425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "CARDIOLIPIN ANTIBODY (IGA)", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "COBALT, SERUM", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "METHYLMALONIC ACID", "code_information": [ { "code": "83921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 247, "minimum": 247 } ] }, { "description": "LH, PEDIATRICS", "code_information": [ { "code": "83002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 237, "minimum": 237 } ] }, { "description": "HISTAMINE, 24-HOUR URINE", "code_information": [ { "code": "83088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "ENDOMYSIAL ANTIBODY SCREEN (IGA) WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "CHLORIDE, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "82436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 45, "minimum": 45 } ] }, { "description": "QUANTITATIVE THYROGLOBULIN WITHOUT THYROGLOBULIN ANTIBODIES", "code_information": [ { "code": "84432", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "VITAMIN B1 (THIAMINE)", "code_information": [ { "code": "84425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "VITAMIN B6, PLASMA", "code_information": [ { "code": "84207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 305, "minimum": 305 } ] }, { "description": "COMPLEMENT C2, FUNCTIONAL", "code_information": [ { "code": "86161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "HANTAVIRUS ANTIBODIES ELISA (IGG)", "code_information": [ { "code": "86790", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 43, "minimum": 43 } ] }, { "description": "OSMOLALITY, FECES", "code_information": [ { "code": "84999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 101, "minimum": 101 } ] }, { "description": "STRIATED MUSCLE ANTIBODY WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "Pain Management, Fentanyl, Quant, Urine", "code_information": [ { "code": "80354", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "VITAMIN A", "code_information": [ { "code": "84590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 269, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 309, "minimum": 309 } ] }, { "description": "HANTAVIRUS ANTIBODIES ELISA (IGM)", "code_information": [ { "code": "86790", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 43, "minimum": 43 } ] }, { "description": "ANTITHROMBIN III ACTIVITY", "code_information": [ { "code": "85300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "PHOSPHATIDYLSERINE ANTIBODIES (IGG)", "code_information": [ { "code": "86148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "IGF BINDING PROTEIN-3 (IGFBP-3)", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 237, "minimum": 237 } ] }, { "description": "LIPOPROTEIN (A)", "code_information": [ { "code": "83695", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "PHOSPHATIDYLSERINE ANTIBODIES (IGA)", "code_information": [ { "code": "86148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "SULFATE, URINE", "code_information": [ { "code": "84392", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "PHOSPHATIDYLSERINE ANTIBODIES (IGM)", "code_information": [ { "code": "86148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "BRCAVANTAGE, COMPREHENSIVE", "code_information": [ { "code": "81162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3983, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1601, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1601, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1601, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1601, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1601, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4573, "minimum": 4573 } ] }, { "description": "COMPLEMENT COMPONENT", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "COMPLEMENT COMPONENT C7", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "COMPLEMENT COMPONENT C8", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "COMPLEMENT COMPONENT C9", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "ARTHRITIS PANEL", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALCOHOL METABOLITES, QUANTITATIVE, URINE", "code_information": [ { "code": "80321", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 106, "minimum": 106 } ] }, { "description": "ANDROSTENEDIONE", "code_information": [ { "code": "82157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "DOPAMINE, PLASMA", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 379, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 435, "minimum": 435 } ] }, { "description": "RUBELLA ANTIBODIES (IGG)", "code_information": [ { "code": "86762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "ANGIOTENSIN II", "code_information": [ { "code": "82163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "GAD65 NEUROLOGICAL SYNDROME ANTIBODY TEST", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 571, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 535, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 614, "minimum": 614 } ] }, { "description": "RUBELLA ANTIBODIES (IGM)", "code_information": [ { "code": "86762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "TRICHINELLA ANTIBODY (IGG), ELISA", "code_information": [ { "code": "86784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "Hepatitis C Viral RNA Genotype 1 NS5a Dr", "code_information": [ { "code": "87902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1017, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1017, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1017, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 996, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1071, "minimum": 1071 } ] }, { "description": "CORTICOSTERONE", "code_information": [ { "code": "82528", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 101, "minimum": 101 } ] }, { "description": "CYSTATIN C", "code_information": [ { "code": "82610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "HYDROMORPHONE FREE (UNCONJUGATED)", "code_information": [ { "code": "80361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "IGD", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "BILE ACIDS, TOTAL", "code_information": [ { "code": "82239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "PHOSPHATE, RANDOM URINE WITH CREATININE", "code_information": [ { "code": "84105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 172, "minimum": 172 } ] }, { "description": "LATEX (K82) IGE", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "POLIOVIRUS (TYPES 1, 3) ANTIBODIES, NEUTRALIZATION 1", "code_information": [ { "code": "86382", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "Catecholamines, plasma", "code_information": [ { "code": "82384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 231, "minimum": 231 } ] }, { "description": "ADENOVIRUS ANTIBODY, SERUM", "code_information": [ { "code": "86603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 222, "minimum": 222 } ] }, { "description": "THROMBOPOIETIN (TPO)", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "BLASTOMYCES ANTIBODY, IMMUNODIFFUSION", "code_information": [ { "code": "86612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 97, "minimum": 97 } ] }, { "description": "HISTOPLASMA ANTIBODY, IMMUNODIFFUSION", "code_information": [ { "code": "86698", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "RIBOSOMAL P ANTIBODY", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "POLIOVIRUS (TYPES 1, 3) ANTIBODIES, NEUTRALIZATION 2", "code_information": [ { "code": "86382", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "LEPTIN", "code_information": [ { "code": "82397", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 265, "minimum": 265 } ] }, { "description": "GLOMERULAR BASEMENT MEMBRANE ANTIBODY (IGG)", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 327, "minimum": 327 } ] }, { "description": "GABAPENTIN", "code_information": [ { "code": "80171", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "BETA-2-GLYCOPROTEIN I ANTIBODY (IGG)", "code_information": [ { "code": "86146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "FLUOXETINE", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "BETA-2-GLYCOPROTEIN I ANTIBODY (IGM)", "code_information": [ { "code": "86146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "KAPPA LIGHT CHAINS, FREE", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 103, "minimum": 103 } ] }, { "description": "INTERLEUKIN-6, HIGHLY SENSITIVE, ELISA", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 471, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 441, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 506, "minimum": 506 } ] }, { "description": "POTASSIUM, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "84133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 45, "minimum": 45 } ] }, { "description": "ACETYLCHOLINE RECEPTOR GANGLIONIC (ALPHA 3) ANTIBODY", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 592, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 637, "minimum": 637 } ] }, { "description": "MYOCARDIAL ANTIBODY SCREEN WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "OXALATE", "code_information": [ { "code": "83945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "DCP (DES-GAMMA-CARBOXY-PROTHROMBIN)", "code_information": [ { "code": "83951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "TRICHOMONAS VAGINALIS, CULTURE, URINE", "code_information": [ { "code": "87081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "FIBRINOGEN ACTIVITY, CLAUSS", "code_information": [ { "code": "85384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "FIBRINOGEN DEGRADATION PRODUCTS (FDP)", "code_information": [ { "code": "85362", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 97, "minimum": 97 } ] }, { "description": "STREPTOCOCCUS PNEUMONIAE ANTIGEN", "code_information": [ { "code": "86403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "PREGNENOLONE", "code_information": [ { "code": "84140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 204, "minimum": 204 } ] }, { "description": "PROTEINASE-3 ANTIBODY", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "VITAMIN B2 (RIBOFLAVIN), PLASMA", "code_information": [ { "code": "84252", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "COENZYME Q10", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 124, "minimum": 124 } ] }, { "description": "KLEIHAUER-BETKE", "code_information": [ { "code": "85460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "VDRL", "code_information": [ { "code": "86592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 93, "minimum": 93 } ] }, { "description": "HISTOPLASMA ANTIGEN", "code_information": [ { "code": "87385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "NEURON SPECIFIC ENOLASE (NSE)", "code_information": [ { "code": "86316", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "TITANIUM", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "ACYLCARNITINE, PLASMA", "code_information": [ { "code": "82017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 499, "minimum": 499 } ] }, { "description": "CATECHOLAMINES, FRACTIONATED, RANDOM URINE 1", "code_information": [ { "code": "82384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "CATECHOLAMINES, FRACTIONATED, RANDOM URINE 2", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "Lymphocyte Subset Panel 3", "code_information": [ { "code": "86359", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 126, "minimum": 126 } ] }, { "description": "AFB (MYCOBACTERIUM) CULTURE 1", "code_information": [ { "code": "87116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "AFB (MYCOBACTERIUM) CULTURE 2", "code_information": [ { "code": "87015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "AFB (MYCOBACTERIUM) CULTURE 3", "code_information": [ { "code": "87206", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "FISH, CML/ALL, BCR/ABL, TRANSLOCATION", "code_information": [ { "code": "88271", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 629, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 616, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 662, "minimum": 662 } ] }, { "description": "FISH, CML/ALL, BCR/ABL, TRANSLOCATION 9;22 1", "code_information": [ { "code": "88271", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 306, "minimum": 306 } ] }, { "description": "FISH, CML/ALL, BCR/ABL, TRANSLOCATION 9;22 2", "code_information": [ { "code": "88271", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 291, "minimum": 291 } ] }, { "description": "FISH, CML/ALL, BCR/ABL, TRANSLOCATION 9;22 3", "code_information": [ { "code": "88275", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 306, "minimum": 306 } ] }, { "description": "CARDIO IQ ADVANCED LIPID PANEL 1", "code_information": [ { "code": "80061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "CARDIO IQ ADVANCED LIPID PANEL 2", "code_information": [ { "code": "83704", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "CARDIO IQ ADVANCED LIPID PANEL 3", "code_information": [ { "code": "82172", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "CARDIO IQ ADVANCED LIPID PANEL 4", "code_information": [ { "code": "83695", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "ALPHA-FETOPROTEIN (AFP) AND AFP-L3", "code_information": [ { "code": "82107", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 113, "minimum": 113 } ] }, { "description": "DCP (DES-GAMMA-CARBOXY-PROTHROMBIN)", "code_information": [ { "code": "83951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "FLUID CULTURE", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 34, "minimum": 34 } ] }, { "description": "GRAM STAIN", "code_information": [ { "code": "87205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO, URINE 1", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO, URINE 2", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO 1", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO 2", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "PAIN MANAGEMENT PROFILE 1 WITH CONFIRMATION, URINE", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 695, "minimum": 695 } ] }, { "description": "MMR (IGG) PANEL (MEASLES, MUMPS, RUBELLA) 1", "code_information": [ { "code": "86735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "MMR (IGG) PANEL (MEASLES, MUMPS, RUBELLA) 2", "code_information": [ { "code": "86765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "MMR (IGG) PANEL (MEASLES, MUMPS, RUBELLA)", "code_information": [ { "code": "86762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "PERNICIOUS ANEMIA DIAGNOSTIC PANEL 1", "code_information": [ { "code": "82607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "PERNICIOUS ANEMIA DIAGNOSTIC PANEL 2", "code_information": [ { "code": "83921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "PERNICIOUS ANEMIA DIAGNOSTIC PANEL 3", "code_information": [ { "code": "86340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "TICK BORNE DISEASE, ACUTE MOLECULAR PANEL", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2238, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2096, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 842, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 842, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 842, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 842, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 842, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2406, "minimum": 2406 } ] }, { "description": "GLUCOSE AND INSULIN TOLERANCE, 4 SPECIMENS 1", "code_information": [ { "code": "82951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "GLUCOSE AND INSULIN TOLERANCE, 4 SPECIMENS 2", "code_information": [ { "code": "82952", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "GLUCOSE AND INSULIN TOLERANCE, 4 SPECIMENS 3", "code_information": [ { "code": "83525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "GLUCOSE AND INSULIN TOLERANCE, 4 SPECIMENS 4", "code_information": [ { "code": "83525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "GLUCOSE AND INSULIN TOLERANCE, 4 SPECIMENS 5", "code_information": [ { "code": "83525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "GLUCOSE AND INSULIN TOLERANCE, 4 SPECIMENS 6", "code_information": [ { "code": "83525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "HEPATITIS E VIRUS (HEV) ANTIBODIES IGG", "code_information": [ { "code": "86790", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "HEPATITIS E VIRUS (HEV) ANTIBODIES IGM", "code_information": [ { "code": "86790", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "HEAVY METALS PANEL, URINE (ARSENIC)", "code_information": [ { "code": "82175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "HEAVY METALS PANEL, URINE (LEAD)", "code_information": [ { "code": "83655", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "HEAVY METALS PANEL, URINE (MERCURY)", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "DRUG SCREEN BY MILLENIUM", "code_information": [ { "code": "G0481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 10", "code_information": [ { "code": "88188", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 1", "code_information": [ { "code": "88184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 2", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 3", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 4", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 5", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 6", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 7", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 8", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "PNH WITH FLAER (HIGH SENSITIVITY) 9", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "StoneRisk Diagnostic Profile", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 684, "minimum": 684 } ] }, { "description": "Protein S Antigen, Total and Free", "code_information": [ { "code": "85305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 681, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 681, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 681, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 667, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 625, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 717, "minimum": 717 } ] }, { "description": "METANEPHRINES, FRACTIONATED, LC/MS/MS, RANDOM URINE 1", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "METANEPHRINES, FRACTIONATED, LC/MS/MS, RANDOM URINE 2", "code_information": [ { "code": "83835", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "JAK2 EXONS 12 AND 13 MUTATIONS, QUALITATIVE, LEUMETA 1", "code_information": [ { "code": "81403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "JAK2 EXONS 12 AND 13 MUTATIONS, QUALITATIVE, LEUMETA 2", "code_information": [ { "code": "81403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "MICROALBUMIN, 24-HOUR URINE (WITH CREATININE) 1", "code_information": [ { "code": "82043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 71, "minimum": 71 } ] }, { "description": "MICROALBUMIN, 24-HOUR URINE (WITH CREATININE) 2", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 71, "minimum": 71 } ] }, { "description": "StoneRisk Cystine Test", "code_information": [ { "code": "82131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "GLUTAMIC ACID DECARBOXYLASE-65 (GAD-65), IA2, AND INSULIN AUTOANTIBODY 1", "code_information": [ { "code": "86337", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "GLUTAMIC ACID DECARBOXYLASE-65 (GAD-65), IA2, AND INSULIN AUTOANTIBODY 2", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "GLUTAMIC ACID DECARBOXYLASE-65 (GAD-65), IA2, AND INSULIN AUTOANTIBODY 3", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "LYME DISEASE ANTIBODIES (IGG, IGM), IMMUNOBLOT 1", "code_information": [ { "code": "86617", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 184, "minimum": 184 } ] }, { "description": "LYME DISEASE ANTIBODIES (IGG, IGM), IMMUNOBLOT 2", "code_information": [ { "code": "86617", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 184, "minimum": 184 } ] }, { "description": "CHROMOSOME ANALYSIS, BLOOD 1", "code_information": [ { "code": "88230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 512, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 479, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 550, "minimum": 550 } ] }, { "description": "CHROMOSOME ANALYSIS, BLOOD 2", "code_information": [ { "code": "88262", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 512, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 479, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 550, "minimum": 550 } ] }, { "description": "CHLAMYDIA/NEISSERIA GONORRHOEAE RNA, TMA, UROGENITAL", "code_information": [ { "code": "87491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "GLUTAMIC ACID DECARBOXYLASE-65 ANTIBODY QUEST 10584", "code_information": [ { "code": "86337", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 236, "minimum": 236 } ] }, { "description": "INSULIN AUTOANTIBODY QUEST 10584", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 236, "minimum": 236 } ] }, { "description": "IA-2 ANTIBODY QUEST 10584", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 236, "minimum": 236 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 1 (SACCHAROMONOSPORA RECTIVIRGULA)", "code_information": [ { "code": "86609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 2 (SACCHAROMONOSPORA VIRIDIS)", "code_information": [ { "code": "86609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 3 ( THERMOACTINOMYCES CANDIDUS)", "code_information": [ { "code": "86609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 4 (THERMOACTINOMYCES SACCHARI)", "code_information": [ { "code": "86609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 5 (THERMOACTINOMYCES VULGARIS)", "code_information": [ { "code": "86609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 6 (ASPERGILLUS FUMIGATUS)", "code_information": [ { "code": "86606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 7 (AUREOBASIDIUM PULLULANS IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 8 ( ALTERNARIA TENUIS IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 9 (CLADOSPORIUM HERBARUM IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HEMOGLOBINOPATHY EVALUATION 1", "code_information": [ { "code": "83021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "HEMOGLOBINOPATHY EVALUATION 2", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 23, "minimum": 23 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL 1", "code_information": [ { "code": "82172", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL 2", "code_information": [ { "code": "82247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL 3", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL 4", "code_information": [ { "code": "83010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL 5", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL 6", "code_information": [ { "code": "84460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "Food Allergy Profile", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "CYTOMEGALOVIRUS ANTIBODIES IGG", "code_information": [ { "code": "86644", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "CYTOMEGALOVIRUS ANTIBODIES IGM", "code_information": [ { "code": "86645", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "BORDETELLA PERTUSSIS ANTIBODIES (IGG, IGA), MAID 1", "code_information": [ { "code": "86615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "BORDETELLA PERTUSSIS ANTIBODIES (IGG, IGA), MAID 2", "code_information": [ { "code": "86615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "BORDETELLA PERTUSSIS ANTIBODIES (IGG, IGA), MAID 3", "code_information": [ { "code": "86615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "BORDETELLA PERTUSSIS ANTIBODIES (IGG, IGA), MAID 4", "code_information": [ { "code": "86615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "Antiphospholipid Syndrome Diagnostic Pan", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 294, "minimum": 294 } ] }, { "description": "RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL, RHEUMATOID FACTOR (IGG)", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL, RHEUMATOID FACTOR (IGA)", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL, RHEUMATOID FACTOR (IGM)", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL, (SS-A)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL, (SS-B)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "CHROMOSOME, BLOOD WITH REFLEX TO POSTNATAL, OLIGO-SNP 1", "code_information": [ { "code": "88230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "CHROMOSOME, BLOOD WITH REFLEX TO POSTNATAL, OLIGO-SNP 2", "code_information": [ { "code": "88262", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, TOTAL 1", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, TOTAL 2", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "TESTOSTERONE, FREE, BIOAVAILABLE AND TOTAL, LC/MS/MS 1", "code_information": [ { "code": "82040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) COMPREHENSIVE DIAGNOSTIC PANEL", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1390, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1302, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1495, "minimum": 1495 } ] }, { "description": "JAK2 V617F MUTATION, QUANTITATIVE 1", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "JAK2 V617F MUTATION, QUANTITATIVE 2", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "JAK2 V617F MUTATION, QUANTITATIVE 3", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "JAK2 V617F MUTATION 4", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "JAK2 V617F MUTATION 5", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "JAK2 V617F MUTATION 6", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "OVA AND PARASITES O+P+TRICHROME", "code_information": [ { "code": "87209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "CARDIOLIPIN ANTIBODIES (IGG)", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "CARDIOLIPIN ANTIBODIES (IGM)", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "GLIADIN ANTIBODY (IGG)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 295, "minimum": 295 } ] }, { "description": "GLIADIN ANTIBODY (IGA)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 295, "minimum": 295 } ] }, { "description": "PHOSPHATE, RANDOM URINE", "code_information": [ { "code": "84105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 172, "minimum": 172 } ] }, { "description": "BK AND JC VIRUS DNA, QUALITATIVE REAL-TIME PCR", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "LACTATE DEHYDROGENASE (LD) ISOENZYME PANEL 1", "code_information": [ { "code": "83615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 152, "minimum": 152 } ] }, { "description": "LACTATE DEHYDROGENASE (LD) ISOENZYME PANEL 2", "code_information": [ { "code": "83625", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 152, "minimum": 152 } ] }, { "description": "IGG SUBCLASSES PANEL 1", "code_information": [ { "code": "82787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "IGG SUBCLASSES PANEL 2", "code_information": [ { "code": "82787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "IGG SUBCLASSES PANEL 3", "code_information": [ { "code": "82787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "IGG SUBCLASSES PANEL 4", "code_information": [ { "code": "82787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "IGG SUBCLASSES PANEL (TOTAL IGG)", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "MYCOPLASMA PPNEUMONIAE ANTIBODY IGG", "code_information": [ { "code": "86738", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 47, "minimum": 47 } ] }, { "description": "MYCOPLASMA PNEUMONIAE ANTIBODY IGM", "code_information": [ { "code": "86738", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 47, "minimum": 47 } ] }, { "description": "FACTOR V LEIDEN 1", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "FACTOR V LEIDEN 2", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "FACTOR V LEIDEN 3", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "FACTOR V LEIDEN 4", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "FACTOR V LEIDEN 5", "code_information": [ { "code": "81200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "HEAVY METALS PANEL, BLOOD (ARSENIC)", "code_information": [ { "code": "82175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "HEAVY METALS PANEL, BLOOD (LEAD)", "code_information": [ { "code": "83655", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "HEAVY METALS PANEL, BLOOD (MERCURY)", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "ASPERGILLUS ANTIBODIES, SERUM (ASPERGILLUS FLAVUS)", "code_information": [ { "code": "86606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "ASPERGILLUS ANTIBODIES, SERUM (ASPERGILLUS FUMIGATUS)", "code_information": [ { "code": "86606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "ASPERGILLUS ANTIBODIES, SERUM ( ASPERGILLUS NIGER)", "code_information": [ { "code": "86606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "COCCIDIOIDES ANTIBODIES (IGG)", "code_information": [ { "code": "86635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "COCCIDIOIDES ANTIBODIES (IGM)", "code_information": [ { "code": "86635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, TOTAL, RANDOM URINE 1", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "EOSINOPHIL COUNT, BLOOD 1", "code_information": [ { "code": "85004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "EOSINOPHIL COUNT, BLOOD 2", "code_information": [ { "code": "85048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "AUTOIMMUNE PANEL, JO-1 ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, DNA (DS) ANTIBODIES", "code_information": [ { "code": "86225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, SJOGREN\u0027S ANTIBODIES (SS-A)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, SJOGREN\u0027S ANTIBODIES (SS-B)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, CRYOGLOBULIN, QUALITATIVE ANALYSIS", "code_information": [ { "code": "82595", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, SEDRATE BY MODIFIED WESTERGREN", "code_information": [ { "code": "85652", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, TSH 3RD GENERATION", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, RNP ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, ANCA SREENCWITH MPO AND PR3", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, ACTIN (SMOOTH MUSCLE) ANTIBODY (IGG)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "AUTOIMMUNE PANEL, PROFILE 284 COMPLEMENT", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "ANCA SCREEN WITH REFLEX TO ANCA TITER", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "MYELOPEROXIDASE AB (MPO)", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "PROTEINASE 3 ANTIBODY", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "SACCHAROMYCES CEREVISIAE AB (ASCA) IGG", "code_information": [ { "code": "86671", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "SACCHAROMYCES CEREVISIAE AB (ASCA) IGA", "code_information": [ { "code": "86671", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "URIC ACID, 24-HOUR URINE", "code_information": [ { "code": "84560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 10 (PENICILLIUM NOTATUM IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 11 ( PHOMA SPP IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 12 (TRICHODERMA VIRIDE IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 13 (MIXED FEATHERS IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "HYPERSENSITIVITY PNEUMONITIS EVALUATION 14 (PIGEON DROPPINGS IGG)", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "IMMUNOFIXATION (IFE), SERUM AND QUANTITATIVE IMMUNOGLOBULINS (IGG, IGA, IGM) 1", "code_information": [ { "code": "86334", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "IMMUNOFIXATION (IFE), SERUM AND QUANTITATIVE IMMUNOGLOBULINS (IGG, IGA, IGM) 2", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "IMMUNOFIXATION (IFE), SERUM AND QUANTITATIVE IMMUNOGLOBULINS (IGG, IGA, IGM) 3", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "IMMUNOFIXATION (IFE), SERUM AND QUANTITATIVE IMMUNOGLOBULINS (IGG, IGA, IGM) 4", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "VARICELLA-ZOSTER VIRUS ANTIBODIES (IGG)", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "VARICELLA-ZOSTER VIRUS ANTIBODIES (IGM)", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "QUAD SCREEN 1", "code_information": [ { "code": "82105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "QUAD SCREEN 2", "code_information": [ { "code": "82677", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "QUAD SCREEN 3", "code_information": [ { "code": "84702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "QUAD SCREEN 4", "code_information": [ { "code": "86336", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "CELIAC DISEASE COMPREHENSIVE PANEL (TISSUE TRANSGLUTAMINASE, IGA WITH REFLEXES)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "CELIAC DISEASE COMPREHENSIVE PANEL (TOTAL IGA WITH REFLEX)", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "I\u0026D PILONIDAL CYST COMP", "code_information": [ { "code": "10081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 303, "minimum": 303 } ] }, { "description": "REPAIR SUP WOUNDS\u003c2.5 CM*", "code_information": [ { "code": "12001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "REPAIR 2.6-7.5CM*", "code_information": [ { "code": "12002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "REPAIR 7.6-12.5 CM*", "code_information": [ { "code": "12004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "REPAIR 12.6-20.0CM", "code_information": [ { "code": "12005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 324, "minimum": 324 } ] }, { "description": "REPAIR 20.1-30.0CM", "code_information": [ { "code": "12006", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "REPAIR \u003e30.0CM", "code_information": [ { "code": "12007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "REPAIR,SIMPLE \u003c2.5 CM*", "code_information": [ { "code": "12011", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "I\u0026D EXTERNAL EAR", "code_information": [ { "code": "69000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "REPAIR, 2.6-5.0 CM*", "code_information": [ { "code": "12013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "REPAIR, 5.1-7.5 CM", "code_information": [ { "code": "12014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "REPAIR, 7.6-12.5 CM", "code_information": [ { "code": "12015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "REPAIR, 12.6-20.0 CM", "code_information": [ { "code": "12016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 342, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 368, "minimum": 368 } ] }, { "description": "REPAIR, 20.1-30.0 CM", "code_information": [ { "code": "12017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 416, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 478, "minimum": 478 } ] }, { "description": "AMPUTATION, FINGER/THUMB", "code_information": [ { "code": "26951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 825, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 825, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 825, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 756, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 868, "minimum": 868 } ] }, { "description": "REPAIR, \u003e30.0 CM", "code_information": [ { "code": "12018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 571, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 535, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 614, "minimum": 614 } ] }, { "description": "REPAIR COMP.SCALP 1.1-2.5", "code_information": [ { "code": "13120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 257, "minimum": 257 } ] }, { "description": "REMOVE,SKIN TAGS ADDL 10", "code_information": [ { "code": "11201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "REPAIR COMP. 2.6 CM-7.5CM", "code_information": [ { "code": "13121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "REPAIR,COMX,CHIN 1.1-2.5", "code_information": [ { "code": "13131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 269, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 309, "minimum": 309 } ] }, { "description": "CLS TXT POST HIP ARTHRO", "code_information": [ { "code": "27265", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "REPAIR COMPLEX 2.6-7.5", "code_information": [ { "code": "13132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 840, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 903, "minimum": 903 } ] }, { "description": "DESTRUCTION, MALIGNANT LESION, 0.6-1 CM, FACE, EARS, EYELIDS, NOSE, MUCOUS MEMBRANES", "code_information": [ { "code": "17281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "DESTRUCTION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIP, MUCOUS MEMBRANES; LESION DIAMETER 1.1 TO 2.0 CM", "code_information": [ { "code": "17282", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "REPAIR COMPLEX 1.1-2.5 CM", "code_information": [ { "code": "13151", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 458, "minimum": 458 } ] }, { "description": "REPAIR COMPLEX 2.6-7.5 CM", "code_information": [ { "code": "13152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 676, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 633, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 727, "minimum": 727 } ] }, { "description": "CLOSURE WOUND EXTEN/COMPL", "code_information": [ { "code": "13160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 819, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 767, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 881, "minimum": 881 } ] }, { "description": "INJECTION INTRALESION \u003c 7", "code_information": [ { "code": "11900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 97, "minimum": 97 } ] }, { "description": "DESTRUCT MAL LESION\u003c.5CM*", "code_information": [ { "code": "17280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "DESTRUCT MAL.LESION,3.1-4", "code_information": [ { "code": "17274", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 433, "minimum": 433 } ] }, { "description": "COLPOSCOPY CERVIX W/BIOPS", "code_information": [ { "code": "57454", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 365, "minimum": 365 } ] }, { "description": "CLOSED TXT PATEL DISLOC", "code_information": [ { "code": "27562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1029, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 963, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1106, "minimum": 1106 } ] }, { "description": "DEBRIDEMENT, OPEN WOUND, FIRST 20 SQ CM OR LESS", "code_information": [ { "code": "97597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "J7042 - 5% DEXTROSE/ .9% NORMAL SALINE", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409794109", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INJECT,TRIGGER POINTS *", "code_information": [ { "code": "20550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "INJECT SM JOINT *", "code_information": [ { "code": "20600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "NEG PRESS WOUND TXT \u003c50CM", "code_information": [ { "code": "97605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 78, "minimum": 78 } ] }, { "description": "INJECT,INTERMEDIATE JNT *", "code_information": [ { "code": "20605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "BIOPSY LOWER LEG SOFT TIS", "code_information": [ { "code": "27614", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 695, "minimum": 695 } ] }, { "description": "CLOSED T/X,RADIAL FRACTUR", "code_information": [ { "code": "25600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 470, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 505, "minimum": 505 } ] }, { "description": "INCISION,DEEP ABSCESS", "code_information": [ { "code": "27301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 792, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 852, "minimum": 852 } ] }, { "description": "EXPL WOUND,ABD/FLANK/BACK", "code_information": [ { "code": "20102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 369, "minimum": 369 } ] }, { "description": "REMOVAL OF F/B SIMPLE*", "code_information": [ { "code": "20520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 256, "minimum": 256 } ] }, { "description": "APPLY CAST,LONG ARM", "code_information": [ { "code": "29065", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "APPLY CAST,SHORT ARM", "code_information": [ { "code": "29075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "APPLY SPLINT,SHORT ARM", "code_information": [ { "code": "29125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "APPLY SPLINT,FINGER", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "APPLICATION,LONG ARM SPNT", "code_information": [ { "code": "29105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "CLOSED TXT ANKLE DISLOC", "code_information": [ { "code": "27840", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 463, "minimum": 463 } ] }, { "description": "APPL. SHORT LEG SPLINT", "code_information": [ { "code": "29515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "ANKLE STRAPPING", "code_information": [ { "code": "29540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "APPLY CAST,SHORT LEG", "code_information": [ { "code": "29405", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "RAPID STREP SCREEN", "code_information": [ { "code": "87880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 41, "minimum": 41 } ] }, { "description": "REMOVE,F/B NASAL *", "code_information": [ { "code": "30300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "CIRCUMCISION, NEWBORN", "code_information": [ { "code": "54150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 390, "minimum": 390 } ] }, { "description": "REMOVE, F/B MOUTH *", "code_information": [ { "code": "40804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 169, "minimum": 169 } ] }, { "description": "APPLY CATH,URETHRA,SIMPLE", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "BIOPSY,VULVA/PERINEUM *", "code_information": [ { "code": "56605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 163, "minimum": 163 } ] }, { "description": "VASECTOMY", "code_information": [ { "code": "55250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "ENDOMETRIAL BIOPSY *", "code_information": [ { "code": "58100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "FOREIGN BODY CORNEAL *", "code_information": [ { "code": "65220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "REMOVE,FOREIGNBODY,EYELID", "code_information": [ { "code": "67938", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "REMOVE FOREIGN BODY EAR", "code_information": [ { "code": "69200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "INFRARED", "code_information": [ { "code": "97026", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 18, "minimum": 18 } ] }, { "description": "EXCIS LESION TENDON FOOT", "code_information": [ { "code": "28090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 480, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 470, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 440, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 505, "minimum": 505 } ] }, { "description": "PROCTOSIGMOIDOSCOPY", "code_information": [ { "code": "45300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "INCISION EXT HEMORRHOID", "code_information": [ { "code": "46083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 216, "minimum": 216 } ] }, { "description": "REMOVAL OF IUD", "code_information": [ { "code": "58301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "FETAL NON-STRESS TEST", "code_information": [ { "code": "59025,26", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "APPLY CAST, FINGER", "code_information": [ { "code": "29086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "CDL PHYS INCL UA \u0026 AUDIOM", "code_information": [ { "code": "99395,CD", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "EPSDT FAMILY PLANNING", "code_information": [ { "code": "99401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "COUNSEL/RISK FACTOR 30MIN", "code_information": [ { "code": "99402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "ARSENIC, 24-HOUR URINE", "code_information": [ { "code": "82175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 379, "minimum": 379 } ] }, { "description": "PANCREATIC ELASTASE-1", "code_information": [ { "code": "82656", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 342, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 393, "minimum": 393 } ] }, { "description": "CELL COUNT AND DIFFERENTIAL, FLUID", "code_information": [ { "code": "89051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "CRYSTALS, FLUID", "code_information": [ { "code": "89060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "COBALT, 24-HOUR URINE", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 142, "minimum": 142 } ] }, { "description": "ALLERGEN (IGE), CONVENTIONAL RAST, ASPEN", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 65, "minimum": 65 } ] }, { "description": "ASPERGILLUS NIGER IGE", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "TRAZODONE", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "ADIPONECTIN", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 181, "minimum": 181 } ] }, { "description": "SEZARY PANEL", "code_information": [ { "code": "88184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "GASTRIC PARIETAL CELL ANTIBODY, ELISA", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 72, "minimum": 72 } ] }, { "description": "IBUPROFEN", "code_information": [ { "code": "80329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "T 4 FREE, DIRECT DIALYSIS", "code_information": [ { "code": "84439", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 107, "minimum": 107 } ] }, { "description": "ALLERGEN ASP. FUMIGATUS IGG", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "FACTOR VII ACTIVITY", "code_information": [ { "code": "85230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "CHROMIUM, SERUM", "code_information": [ { "code": "82495", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "BORDETELLA PERTUSSIS/PARAPERTUSSIS, CULTURE", "code_information": [ { "code": "87081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "FLECAINIDE", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "ALPHA-1 ANTITRYPSIN (AAT) MUTATION ANALYSIS", "code_information": [ { "code": "81332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 749, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 733, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 686, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 788, "minimum": 788 } ] }, { "description": "COUNSEL/RISK FACTOR 15MIN", "code_information": [ { "code": "99401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "ANTEPARTUM CARE ONLY;4-6", "code_information": [ { "code": "59425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 588, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 675, "minimum": 675 } ] }, { "description": "ANTEPARTUM CARE;7 OR MORE", "code_information": [ { "code": "59426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1039, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1039, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1039, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1017, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 953, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1094, "minimum": 1094 } ] }, { "description": "POSTPARTUM CARE ONLY", "code_information": [ { "code": "59430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 235, "minimum": 235 } ] }, { "description": "TX INCOMP ABORT, ANY TRIM", "code_information": [ { "code": "59812", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "PROLONGED SERVICE", "code_information": [ { "code": "99358", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 91, "minimum": 91 } ] }, { "description": "BISMUTH, BLOOD", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "IGG SUBCLASS 4", "code_information": [ { "code": "82787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "IMMUNE CELL FUNCTION", "code_information": [ { "code": "86352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 753, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 753, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 753, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 737, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 691, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 793, "minimum": 793 } ] }, { "description": "CLONAZEPAM", "code_information": [ { "code": "80346", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 123, "minimum": 123 } ] }, { "description": "TBII (THYROTROPIN-BINDING INHIBITORY IMMUNOGLOBULIN)", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 481, "minimum": 481 } ] }, { "description": "TRAB (TSH RECEPTOR BINDING ANTIBODY)", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 331, "minimum": 331 } ] }, { "description": "CHLAMYDOPHILA PNEUMONIAE, DNA, QUALITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87486", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "ACETONE, QUALITATIVE, URINE", "code_information": [ { "code": "81005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "ADENOVIRUS DNA, QUALITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 305, "minimum": 305 } ] }, { "description": "IA-2 Antibody", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 414, "minimum": 414 } ] }, { "description": "HEPARIN-INDUCED PLATELET ANTIBODY", "code_information": [ { "code": "86022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 359, "minimum": 359 } ] }, { "description": "PARANEOPLASTIC ANTIBODY EVALUATION W/REFLEX TO TITER AND LINE BLOT, BASIC 86255", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3475, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3990, "minimum": 3990 } ] }, { "description": "LACTIC ACID, PLASMA", "code_information": [ { "code": "83605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "ANTI-MULLERIAN HORMONE (AMH), FEMALE", "code_information": [ { "code": "82397", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "PAIN MANAGEMENT, TRAMADOL, QUANTITATIVE, URINE", "code_information": [ { "code": "80373", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "STREPTOCOCCUS PNEUMONIAE ANTIBODY (IGG) (23 SEROTYPES), MAID", "code_information": [ { "code": "86317", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 315, "minimum": 315 } ] }, { "description": "ALDOSTERONE, 24-HOUR URINE", "code_information": [ { "code": "82088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "AMIKACIN, RANDOM", "code_information": [ { "code": "80150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 132, "minimum": 132 } ] }, { "description": "AMIKACIN, PEAK", "code_information": [ { "code": "80150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 132, "minimum": 132 } ] }, { "description": "AMIKACIN, TROUGH", "code_information": [ { "code": "80150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 324, "minimum": 324 } ] }, { "description": "HU ANTIBODY SCREEN WITH REFLEX TO TITER AND WESTERN BLOT", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 379, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 435, "minimum": 435 } ] }, { "description": "CORTISOL, P.M.", "code_information": [ { "code": "82533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 59, "minimum": 59 } ] }, { "description": "CRYPTOSPORIDIUM ANTIGEN, DFA", "code_information": [ { "code": "87015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 126, "minimum": 126 } ] }, { "description": "JC Polyoma Virus DNA, Qual, PCR, Plasma", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 215, "minimum": 215 } ] }, { "description": "GENTAMICIN, RANDOM", "code_information": [ { "code": "80170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "CA 15-3", "code_information": [ { "code": "86300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "GENTAMICIN, PEAK", "code_information": [ { "code": "80170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "GENTAMICIN, TROUGH", "code_information": [ { "code": "80170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "EPSTEIN-BARR VIRUS NUCLEAR ANTIGEN (EBNA) ANTIBODY (IGG)", "code_information": [ { "code": "86664", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "BUPRENORPHINE, QUANTITATIVE, URINE", "code_information": [ { "code": "80348", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "CYCLOSPORINE WHOLE MOLECULE", "code_information": [ { "code": "80158", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 101, "minimum": 101 } ] }, { "description": "INHIBIN A", "code_information": [ { "code": "86336", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "VITAMIN D, 25-HYDROXY", "code_information": [ { "code": "82306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "OSMOLALITY, URINE", "code_information": [ { "code": "83935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 97, "minimum": 97 } ] }, { "description": "ALLERGEN SPECIFIC (M207) IGG ASPERGILLUS NIGER", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "OSMOLALITY, SERUM", "code_information": [ { "code": "83930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "DOPAMINE, RANDOM URINE", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "LYMPHOCYTE SUBSET PANEL 5", "code_information": [ { "code": "86361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "ALBUMIN, PLEURAL FLUID", "code_information": [ { "code": "82042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 81, "minimum": 81 } ] }, { "description": "GLUCOSE, PLEURAL FLUID", "code_information": [ { "code": "82945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "MRSA, NASAL SWAB BY PCR", "code_information": [ { "code": "87641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "TOTAL PROTEIN, PLEURAL FLUID", "code_information": [ { "code": "84157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 108, "minimum": 108 } ] }, { "description": "ALPHA-1-ANTITRYPSIN (AAT) PHENOTYPE", "code_information": [ { "code": "82104", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 376, "minimum": 376 } ] }, { "description": "ASPERGILLUS FUMIGATUS IGE", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "HEMOSIDERIN, QUALITATIVE, RANDOM URINE", "code_information": [ { "code": "83070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "PROTHROMBIN (FACTOR II) 20210G?A MUTATION ANALYSIS", "code_information": [ { "code": "81240", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 424, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 397, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 456, "minimum": 456 } ] }, { "description": "UREA NITROGEN, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "84540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "Chromosomal Microarray, Postnatal, ClariSure(R) Oligo-SNP", "code_information": [ { "code": "81229", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3875, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3793, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3553, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1428, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1428, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1428, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1428, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1428, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4079, "minimum": 4079 } ] }, { "description": "HEPATITIS B VIRUS DRUG RESISTANCE, GENOTYPE, AND BCP/PRECORE MUTATIONS", "code_information": [ { "code": "87912", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 457, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 491, "minimum": 491 } ] }, { "description": "BETA-2-GLYCOPROTEIN I ANTIBODY (IGA)", "code_information": [ { "code": "86146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "HISTAMINE, PLASMA", "code_information": [ { "code": "83088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 396, "minimum": 396 } ] }, { "description": "TREPONEMA PALLIDUM DNA, QUALITATIVE REAL-TIME PCR", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "OXYCARBAZEPINE METABOLITE", "code_information": [ { "code": "83789", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "VALPROIC ACID, TOTAL AND FREE", "code_information": [ { "code": "80164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 205, "minimum": 205 } ] }, { "description": "NOREPINEPHRINE, PLASMA", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "ECHINOCOCCUS ANTIBODY (IGG), EIA WITH REFLEX TO WESTERN BLOT", "code_information": [ { "code": "86682", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "PARVOVIRUS B19 ANTIBODY (IGG)", "code_information": [ { "code": "86747", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "PARVOVIRUS B19 ANTIBODY (IGM)", "code_information": [ { "code": "86747", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "VISCOSITY, SERUM", "code_information": [ { "code": "85810", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "INFLUENZA A H1N1", "code_information": [ { "code": "87502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "21-HYDROXYLASE ANTIBODY", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "PROTEIN C ACTIVITY", "code_information": [ { "code": "85303", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 184, "minimum": 184 } ] }, { "description": "CHOLINESTERASE, SERUM", "code_information": [ { "code": "82480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 46, "minimum": 46 } ] }, { "description": "FELBAMATE", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 86, "minimum": 86 } ] }, { "description": "TOPAMAX", "code_information": [ { "code": "80201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "COLLAGEN TYPE I C-TELOPEPTIDE (CTX)", "code_information": [ { "code": "82523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "ARGININE VASOPRESSIN (AVP, ANTIDIURETIC HORMONE)", "code_information": [ { "code": "84588", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 511, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 511, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 511, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 469, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 538, "minimum": 538 } ] }, { "description": "SICKLE CELL SCREEN", "code_information": [ { "code": "85660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 133, "minimum": 133 } ] }, { "description": "PROCOLLAGEN TYPE I INTACT N TERMINAL PROPEPTIDE", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 154, "minimum": 154 } ] }, { "description": "ADENOVIRUS ANTIGEN, DFA", "code_information": [ { "code": "87260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "ADENOSINE DEAMINASE, BLOOD", "code_information": [ { "code": "84311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "MUSCLE FIBER FECAL", "code_information": [ { "code": "89160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "CD4/T-HELPER CELL PROFILE (LYMPHOCYTE SUBSET PANEL 4)", "code_information": [ { "code": "86360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 784, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 900, "minimum": 900 } ] }, { "description": "PARANEOPLASTIC ANTIBODY EVALUATION W/REFLEX TO TITER AND LINE BLOT, BASIC 83519", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3791, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3475, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1397, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3990, "minimum": 3990 } ] }, { "description": "TUMOR NECROSIS FACTOR- ALPHA, HIGHLY SENSITIVE", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 248, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 267, "minimum": 267 } ] }, { "description": "EOSINOPHIL, URINE", "code_information": [ { "code": "85999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "I\u0026D BARTHOLIN GLAND ABSCE", "code_information": [ { "code": "56420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "MEATOTOMY, CUTTING MEATUS", "code_information": [ { "code": "53020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 331, "minimum": 331 } ] }, { "description": "SNF SUBSEQ, 30MIN NF", "code_information": [ { "code": "0525", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 162, "minimum": 162 } ] }, { "description": "BLOOD,OCCULT", "code_information": [ { "code": "82270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "GLUCOSE", "code_information": [ { "code": "82962", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "CLSD TXT RADIAL/ULNR FRAC", "code_information": [ { "code": "25560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 379, "minimum": 379 } ] }, { "description": "WET MOUNT", "code_information": [ { "code": "87210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 16, "minimum": 16 } ] }, { "description": "ADMIN.INF.VAC 6-35 MO.", "code_information": [ { "code": "90657", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "GLUCOSE, PERITONEAL FLUID", "code_information": [ { "code": "82945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "ADMIN.INF.VAC. \u003e3 YRS.", "code_information": [ { "code": "90658", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "INSERT OF VAGINAL PASSERY", "code_information": [ { "code": "57160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 97, "minimum": 97 } ] }, { "description": "COLPOSCOPY /W BIOPSY", "code_information": [ { "code": "57454", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 365, "minimum": 365 } ] }, { "description": "BIOPSY SINGLE OR MULTIPLE", "code_information": [ { "code": "57500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "INSERTION OF IUD", "code_information": [ { "code": "58300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "REMOVE RECTAL OBSTRUCTION", "code_information": [ { "code": "45915", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "CURETTAGE POSTPARTUM", "code_information": [ { "code": "59160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "ASPIRATION OF ABSCESS*", "code_information": [ { "code": "10160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "I\u0026D COMPLEX,WOUND INF", "code_information": [ { "code": "10180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 264, "minimum": 264 } ] }, { "description": "I\u0026D HEMOTOMA,FLUID RET*", "code_information": [ { "code": "10140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "DEBRIDE,SUBQ TISSUE", "code_information": [ { "code": "11042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "REMOVAL F/B MOUTH COMP.", "code_information": [ { "code": "40805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "EXCISE,LESION,\u003c=0.5CM", "code_information": [ { "code": "11400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 248, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 267, "minimum": 267 } ] }, { "description": "EXCISE,LESION,1.1-2.0CM", "code_information": [ { "code": "11402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "EXCISE,LESION,2.1-3.0CM", "code_information": [ { "code": "11403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "EXCISE,LESION,3.1-4.0CM", "code_information": [ { "code": "11404", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 298, "minimum": 298 } ] }, { "description": "EXCISE,LESION,\u003e4.0CM", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 394, "minimum": 394 } ] }, { "description": "EXCISE,LESION,\u003c=0.5CM", "code_information": [ { "code": "11420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11421", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 284, "minimum": 284 } ] }, { "description": "EXCISE LESION 1.1-2.0 CM", "code_information": [ { "code": "11422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 313, "minimum": 313 } ] }, { "description": "EXCISE,LESION,2.1-3.0CM", "code_information": [ { "code": "11423", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11424", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 332, "minimum": 332 } ] }, { "description": "REMOVE FB CONJUNCT EMBED", "code_information": [ { "code": "65210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "SPINAL PUNCTURE DIAGNOSTI", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "DEBRIDEMENT 10% BODY SURF", "code_information": [ { "code": "11000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "LD, PERITONEAL FLUID", "code_information": [ { "code": "83615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 56, "minimum": 56 } ] }, { "description": "EXCIS PILONIDL CYST/SINUS", "code_information": [ { "code": "10021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 247, "minimum": 247 } ] }, { "description": "CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL BREAST EXAMINATION", "code_information": [ { "code": "G0101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "EXPLORE PENETRATING WOUND", "code_information": [ { "code": "20103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 422, "minimum": 422 } ] }, { "description": "INIT PREV EXAM, NEW MCARE", "code_information": [ { "code": "G0402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "I\u0026D PERIANAL ABSCESS SUPR", "code_information": [ { "code": "46050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 255, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 274, "minimum": 274 } ] }, { "description": "INJECT, CARPAL TUNNEL", "code_information": [ { "code": "20526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "INJECT, SINGLE TENDON", "code_information": [ { "code": "20551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "INJ,\u003e=1 TRIG PT,\u003e=3 MUSCL", "code_information": [ { "code": "20553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 109, "minimum": 109 } ] }, { "description": "KOH SLIDE", "code_information": [ { "code": "87220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "ANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED PATIENT", "code_information": [ { "code": "S0612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "EXCISN OF SEBACEOUS CYST", "code_information": [ { "code": "10040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 134, "minimum": 134 } ] }, { "description": "PARING/CUTTING 2-4 LESION", "code_information": [ { "code": "11056", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 85, "minimum": 85 } ] }, { "description": "DEBRIDE ECZEM SKIN ADD\u0027L", "code_information": [ { "code": "11001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "INCISIONAL BIOPSY OF SKIN (EG WEDGE) (INC SIMPLE CLOSURE) SINGLE LESION", "code_information": [ { "code": "11106", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 184, "minimum": 184 } ] }, { "description": "SPIROMETRY, BASELINE", "code_information": [ { "code": "94010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "SUBLUNGUAL HEMATOMA", "code_information": [ { "code": "11740", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "REPAIR LACER \u003c=2.5 MOUTH", "code_information": [ { "code": "41250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "SHAVE BX TRUNK \u003c0.5CM", "code_information": [ { "code": "11300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "SHAVE BX TRUNK 0.6-1.00CM", "code_information": [ { "code": "11301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "SHAVE BX TRUNK 1.1-2.0CM", "code_information": [ { "code": "11302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; DIAM 0.6-1.0 CM", "code_information": [ { "code": "11306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "SHAVE EPIDERM LESION .5CM", "code_information": [ { "code": "11310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM", "code_information": [ { "code": "11311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "FAMILY CONSULT EST PT", "code_information": [ { "code": "99212,CS", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "SPLIT GRAFT 1ST 100 SQ CM", "code_information": [ { "code": "15100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 811, "minimum": 811 } ] }, { "description": "FULL THCK GRAFT TRNK\u003c20CM", "code_information": [ { "code": "15200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 803, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 752, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 863, "minimum": 863 } ] }, { "description": "DRESS CHG UNDER ANESTHES", "code_information": [ { "code": "15852", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "I \u0026 D OF BURNS SMALL", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 125, "minimum": 125 } ] }, { "description": "BLADDER CATH NON INDWELL", "code_information": [ { "code": "51701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "BLADDER CATH TEMP INDWELL", "code_information": [ { "code": "51702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "BLADDER INSTILLATION", "code_information": [ { "code": "51720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 213, "minimum": 213 } ] }, { "description": "WEDGE EXCISION/SKIN/NAIL", "code_information": [ { "code": "11765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "FINE NEEDLE ASPIR W/O IMG", "code_information": [ { "code": "11771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 807, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 790, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 739, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 849, "minimum": 849 } ] }, { "description": "EXCISION TUMOR BACK/FLANK", "code_information": [ { "code": "21930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 529, "minimum": 529 } ] }, { "description": "TXT WOUND DEHIS SIMPLE", "code_information": [ { "code": "12020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 341, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 313, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 359, "minimum": 359 } ] }, { "description": "ASPIR/INJEC GANGLION CYST", "code_information": [ { "code": "20612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "SIALOLITHOTOMY UNCOMPLICA", "code_information": [ { "code": "42330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 316, "minimum": 316 } ] }, { "description": "INTRO NEEDLE/CATH VEIN *", "code_information": [ { "code": "36000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 19, "minimum": 19 } ] }, { "description": "T/X ELBOW DISLOCAT W/O AN", "code_information": [ { "code": "24600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 548, "minimum": 548 } ] }, { "description": "CLOSED TREAT RADIAL HEAD", "code_information": [ { "code": "24640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "RADIAL HEAD W/O MAL", "code_information": [ { "code": "24650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "EXCISION GANGLION CYST WR", "code_information": [ { "code": "25111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "AUDIOMETRY, PURE TONE", "code_information": [ { "code": "92552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 38, "minimum": 38 } ] }, { "description": "CLOSED TX OF RADIAL", "code_information": [ { "code": "25565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 679, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 730, "minimum": 730 } ] }, { "description": "EXC LES OF TENDON SHEATH", "code_information": [ { "code": "26160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "DRAIN,FINGER ABCESS,SIMP*", "code_information": [ { "code": "26010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "CLOSED T/X METACARPAL FRA", "code_information": [ { "code": "26600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 383, "minimum": 383 } ] }, { "description": "PHALANGEL SHAFT FRACTURE", "code_information": [ { "code": "26725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 425, "minimum": 425 } ] }, { "description": "CLOSED TREAT PATELLAR DIS", "code_information": [ { "code": "27560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 452, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 486, "minimum": 486 } ] }, { "description": "SPLINT THIGH TO TOES", "code_information": [ { "code": "29505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "CTRL NASOPHARYNG HEMORRHA", "code_information": [ { "code": "42970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 764, "minimum": 764 } ] }, { "description": "DRAIN ABCESS NASAL INTERN", "code_information": [ { "code": "30000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "TUBE THORACOSTOMY", "code_information": [ { "code": "32551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 353, "minimum": 353 } ] }, { "description": "REPAIR COMP.\u003c=5CM, EA ADD", "code_information": [ { "code": "13122", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "REPAIR,COMPLX,ADDL,\u003c=5CM", "code_information": [ { "code": "13133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "CONTROL NASAL HEMMOR SMP*", "code_information": [ { "code": "30901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "VENIPUNCTURE\u003c3YR FEMORAL", "code_information": [ { "code": "36400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "CLOSED TREATMENT SHOULDER DISLOCATION", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "DILATE FEMALE URETH, INIT", "code_information": [ { "code": "53660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "DILATE FEMALE URETH SUBSQ", "code_information": [ { "code": "53661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "LIGATION VARICOSE VEIN", "code_information": [ { "code": "37785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "INCISION, BURSA", "code_information": [ { "code": "23931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 305, "minimum": 305 } ] }, { "description": "DESTRUCTION OF LESION, PENIS, SIMPLE; ELECTRODESICCATION", "code_information": [ { "code": "54055", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 315, "minimum": 315 } ] }, { "description": "INJ, ANES AGENT ILIO NRVS", "code_information": [ { "code": "64425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "I \u0026 D TRANSRECTAL ABCESS", "code_information": [ { "code": "45005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "I\u0026D DEEP SUPRALEVATOR ABS", "code_information": [ { "code": "45020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 416, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 478, "minimum": 478 } ] }, { "description": "ANASCOPE", "code_information": [ { "code": "46600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 66, "minimum": 66 } ] }, { "description": "IMMUN.PNEUMOCOCCAL VAC.", "code_information": [ { "code": "90732", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "CLOSED TX ULNAR FRACTURE", "code_information": [ { "code": "24670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 420, "minimum": 420 } ] }, { "description": "EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 973, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 973, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 973, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 952, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 892, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1024, "minimum": 1024 } ] }, { "description": "I\u0026D VULVA/PERINEAL ABCESS", "code_information": [ { "code": "56405", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 193, "minimum": 193 } ] }, { "description": "EXCISION, BIOPSY FOREARM", "code_information": [ { "code": "25065", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 295, "minimum": 295 } ] }, { "description": "OFFICE VISIT,EST,COMPREH", "code_information": [ { "code": "99215", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 201, "minimum": 201 } ] }, { "description": "DRAIN-SCROTAL WALL ABCESS", "code_information": [ { "code": "55100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 548, "minimum": 548 } ] }, { "description": "FIRE DEPT PHYS EMPL LVL 1", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "FIRE DEPT PHYS VOLUNTEER", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "EXCISE,LESION,\u003e4.0CM", "code_information": [ { "code": "11426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 471, "minimum": 471 } ] }, { "description": "EXCISE,LESION,\u003c=0.5CM", "code_information": [ { "code": "11440", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11441", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "EXCISE,LESION,1.1-2.0CM", "code_information": [ { "code": "11442", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 342, "minimum": 342 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11444", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 484, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 443, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 509, "minimum": 509 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 524, "minimum": 524 } ] }, { "description": "EXCISE,MAL LESION ARMS\u003c.5", "code_information": [ { "code": "11600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 336, "minimum": 336 } ] }, { "description": "CHEMOTHERAPY ADMIN SUBCUT", "code_information": [ { "code": "96402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "EXCISE LESION 0.6-1 CM", "code_information": [ { "code": "11601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 405, "minimum": 405 } ] }, { "description": "EX MAL LESION \u003c.5 CM", "code_information": [ { "code": "11620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 348, "minimum": 348 } ] }, { "description": "INTERCOSTAL NERVE SINGLE", "code_information": [ { "code": "64420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "INJEC,ANESTH AGENT; NERVE", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11621", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 417, "minimum": 417 } ] }, { "description": "PROCTOSIGMOIDOSCOPY", "code_information": [ { "code": "45300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "EXCISE,LESION,\u003c=0.5CM", "code_information": [ { "code": "11640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 248, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 267, "minimum": 267 } ] }, { "description": "EXCISE,LESION,0.6-1.0CM", "code_information": [ { "code": "11641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 407, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 398, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 428, "minimum": 428 } ] }, { "description": "EXCISE LESION 1.1-2.0 CM", "code_information": [ { "code": "11642", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 499, "minimum": 499 } ] }, { "description": "EXCISE LESION 2.1-3 CM", "code_information": [ { "code": "11643", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 579, "minimum": 579 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11644", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 594, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 557, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 639, "minimum": 639 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11646", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 726, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 711, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 764, "minimum": 764 } ] }, { "description": "PERITONEOCENTESIS,ABD/PE*", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 215, "minimum": 215 } ] }, { "description": "INSERT CENTRL VENOUS CATH", "code_information": [ { "code": "36556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 240, "minimum": 240 } ] }, { "description": "INSERT TUNNEL CATH \u003e=5YRS", "code_information": [ { "code": "36558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 522, "minimum": 522 } ] }, { "description": "DEBRIDE,NAILS,\u003c=5", "code_information": [ { "code": "11720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 53, "minimum": 53 } ] }, { "description": "CLOSED TXT METACARP FRACT", "code_information": [ { "code": "26605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 379, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 435, "minimum": 435 } ] }, { "description": "DEBRIDE NAILS \u003e6", "code_information": [ { "code": "11721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 86, "minimum": 86 } ] }, { "description": "CLOSED TX DISLOC, THUMB", "code_information": [ { "code": "26641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 474, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 444, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 510, "minimum": 510 } ] }, { "description": "AVUL,NAIL PLATE,1 SIMPLE*", "code_information": [ { "code": "11730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "AVUL,NAIL PLATE,EA ADD", "code_information": [ { "code": "11732", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "CRYOTHERAPY,ACNE*", "code_information": [ { "code": "17340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "CLSD REDUCT MCP DISLOC WO", "code_information": [ { "code": "26700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 495, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 463, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 532, "minimum": 532 } ] }, { "description": "EXCISE,NAIL,PART/COMPLETE", "code_information": [ { "code": "11750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 394, "minimum": 394 } ] }, { "description": "CLSD TXT DISTL PHALN FRAC", "code_information": [ { "code": "26750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 281, "minimum": 281 } ] }, { "description": "TX INTERPHAL JOINT DISLOC", "code_information": [ { "code": "26770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 435, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 426, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 399, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 458, "minimum": 458 } ] }, { "description": "CLSD REDUCT FINGER DISLOC", "code_information": [ { "code": "26775", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 576, "minimum": 576 } ] }, { "description": "CORRECTION OF TRICHIASIS; EPLIATION, BY FORCEPS ONLY", "code_information": [ { "code": "67820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 169, "minimum": 169 } ] }, { "description": "DESTRUCT LESION EYELID", "code_information": [ { "code": "67850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 272, "minimum": 272 } ] }, { "description": "REMOVE,CONTRACEP CAPSULES", "code_information": [ { "code": "11976", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 256, "minimum": 256 } ] }, { "description": "I\u0026D PILONIDAL CYST*", "code_information": [ { "code": "10080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "SOLUBLE TRANSFERRIN RECEPTOR", "code_information": [ { "code": "84238", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "SEROTONIN RELEASE ASSAY (SRA), UNFRACTIONATED HEPARIN", "code_information": [ { "code": "86022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "PROTEIN, TOTAL, PERITONEAL FLUID", "code_information": [ { "code": "84157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 69, "minimum": 69 } ] }, { "description": "Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older", "code_information": [ { "code": "36569", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "INCISION, BURSA", "code_information": [ { "code": "23931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 305, "minimum": 305 } ] }, { "description": "INCISION, BURSA", "code_information": [ { "code": "23931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 175, "minimum": 175 } ] }, { "description": "Injection, ceftaroline fosamil, 10 mg", "code_information": [ { "code": "J0712", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8, "minimum": 8 } ] }, { "description": "TIGECYCLINE 1MG / 50MG VIAL", "code_information": [ { "code": "J3243", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8, "minimum": 8 } ] }, { "description": "J7050 - Infusion, normal saline solution, 250 cc", "drug_information": { "unit": "250", "type": "ML" }, "code_information": [ { "code": "00409798302", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J7040 - Infusion, normal saline solution, sterile (500 ml=1 unit)", "drug_information": { "unit": "500", "type": "ML" }, "code_information": [ { "code": "00409798303", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION 50ML", "drug_information": { "unit": "50", "type": "ML" }, "code_information": [ { "code": "00409798436", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO, SERUM", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 266, "minimum": 266 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO, URINE", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 294, "minimum": 294 } ] }, { "description": "PHEOCHROMOCYTOMA EVALUATION", "code_information": [ { "code": "82382", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "GLYBURIDE 2.5 MG TABLET", "drug_information": { "unit": "2.5", "type": "UN" }, "code_information": [ { "code": "00093834301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LYMPHOCYTE SUBSET PANEL 5 (CD4 CD4)", "code_information": [ { "code": "86361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 85, "minimum": 85 } ] }, { "description": "Ileoscopy, through stoma; diagnostic, inc collection of specimen(s) by brushing or washing, when performed", "code_information": [ { "code": "44380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1077, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1009, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1158, "minimum": 1158 } ] }, { "description": "Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not inc ileum; diagnostic, inc collection of specimen(s) by brushing or washing", "code_information": [ { "code": "44360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1347, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1261, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 507, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1448, "minimum": 1448 } ] }, { "description": "ANTIDIURETIC HORMONE (ADH), PLASMA", "code_information": [ { "code": "84588", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 500, "minimum": 500 } ] }, { "description": "DIABETIC SHOE", "code_information": [ { "code": "A5508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 125, "minimum": 125 } ] }, { "description": "QUESTASSURED FOR INFANTS, 25-HYDROXYVITAMIN D", "code_information": [ { "code": "82306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "REDUCING SUBSTANCES, STOOL", "code_information": [ { "code": "84376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "STOOL PH", "code_information": [ { "code": "83986", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 20, "minimum": 20 } ] }, { "description": "HUBER NEEDLE", "code_information": [ { "code": "A4212", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "CRYOGLOBULIN SCREEN WITH REFLEX TO CRYOGLOBULIN PANEL", "code_information": [ { "code": "82595", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 70, "minimum": 70 } ] }, { "description": "Protein, total, except by refractometry; serum", "code_information": [ { "code": "84155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 124, "minimum": 124 } ] }, { "description": "Protein; electrophoretic fractionation and quantitation, serum", "code_information": [ { "code": "84165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 123, "minimum": 123 } ] }, { "description": "HEPARIN, ANTI-XA", "code_information": [ { "code": "85520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 230, "minimum": 230 } ] }, { "description": "WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY", "code_information": [ { "code": "G0168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "Specimen Collection for Paternity", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 35, "minimum": 35 } ] }, { "description": "PROTEIN C ANTIGEN", "code_information": [ { "code": "85302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "PROCAINAMIDE 1GM INJ", "code_information": [ { "code": "J2690", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "SPUTUM INDUCTION", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "P/T EVAL LOW COMPLEX 30 MINS (FM)", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 303, "minimum": 303 } ] }, { "description": "P/T EVAL LOW COMPLEX 45 MINS (FM)", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 364, "minimum": 364 } ] }, { "description": "ANALYZER ANA, IFA WITH REFLEX TITER/PATTERN, SYSTEMIC AUTOIMMUNE PANEL 1", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1089, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1089, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1089, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1066, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 998, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1146, "minimum": 1146 } ] }, { "description": "CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) PROGNOSTIC PANEL, COMPREHENSIVE", "code_information": [ { "code": "82232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1827, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1827, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1827, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1788, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1675, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 673, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 673, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 673, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 673, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 673, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1923, "minimum": 1923 } ] }, { "description": "SOC TB Testing", "code_information": [ { "code": "86580", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "PINE NUT (F253) IGE", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 24, "minimum": 24 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV - ID (SOUTH), NV", "code_information": [ { "code": "82785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 240, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 258, "minimum": 258 } ] }, { "description": "HEREDITARY HEMOCHROMATOSIS DNA MUTATION ANALYSIS", "code_information": [ { "code": "81256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 493, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 530, "minimum": 530 } ] }, { "description": "HISTOPLASMA ANTIBODY PANEL, CF AND ID, SERUM", "code_information": [ { "code": "86698", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 238, "minimum": 238 } ] }, { "description": "COCCIDIOIDES ANTIBODY, CF AND ID, SERUM", "code_information": [ { "code": "86635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 206, "minimum": 206 } ] }, { "description": "CULTURE, VIRAL, BODY FLUIDS, TISSUES", "code_information": [ { "code": "87252", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 270, "minimum": 270 } ] }, { "description": "MATERNAL SERUM SCREEN 4", "code_information": [ { "code": "81511", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "TOBACCO LEAF (RO201) IGE", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 58, "minimum": 58 } ] }, { "description": "HEPATITIS D VIRUS (HDV) ANTIBODY, TOTAL", "code_information": [ { "code": "86692", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "IMADM PRQ ID SUBQ/IM NJXS EA VACCINE", "code_information": [ { "code": "90472", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "SOBOXONE 8/2MG SL FLM", "code_information": [ { "code": "J0574", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8, "minimum": 8 } ] }, { "description": "INDIRECT ANTIGLOBULIN TEST", "code_information": [ { "code": "86850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 193, "minimum": 193 } ] }, { "description": "PROSTATIC ACID PHOSPHATASE (PAP)", "code_information": [ { "code": "84066", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "STREPTOCOCCUS PNEUMONIAE ANTIGEN DETECTION, LA", "code_information": [ { "code": "86403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 143, "minimum": 143 } ] }, { "description": "TOPIRAMATE (TOPAMAX)", "code_information": [ { "code": "80201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "LIVER FIBROSIS, FIBROTEST-ACTITEST PANEL", "code_information": [ { "code": "81596", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 433, "minimum": 433 } ] }, { "description": "MAGNESIUM, RBC", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "GLIADIN (DEAMIDATED) ANTIBODY (IGG, IGA)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS INCLUDES REMOVAL, WEHN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDEANCE: NOT REGUIRING REVISION OF GASTROSTOMY TRACT", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 240, "minimum": 240 } ] }, { "description": "ISLET CELL ANTIBODY SCREEN WITH REFLEX TO TITER", "code_information": [ { "code": "86341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 266, "minimum": 266 } ] }, { "description": "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT", "code_information": [ { "code": "11982", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "HEPATITIS A ANTIBODY, TOTAL WITH REFLEX TO IGM", "code_information": [ { "code": "86708", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "AZITHROMYCIN monohydrate 250 MG TABLET", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "59762306002", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACEPHEN 120 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "120", "type": "UN" }, "code_information": [ { "code": "00713011812", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACEPHEN 325 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "325", "type": "UN" }, "code_information": [ { "code": "00713016412", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ACEPHEN 650 MG RECTAL SUPPOSITORY", "drug_information": { "unit": "650", "type": "UN" }, "code_information": [ { "code": "00713016512", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHILDREN\u0027S PAIN \u0026 FEVER RELIEF 160 MG/5 ML ORAL ELIXIR", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "58657052016", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CITROMA ORAL SOLUTION", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00869068638", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "EYE WASH SOLUTION 118mL", "drug_information": { "unit": "118", "type": "ML" }, "code_information": [ { "code": "10119000252", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CETACAINE SPRAY 5g single use", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "10223020104", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LIDOCAINE 2 % MUCOSAL SOLUTION", "drug_information": { "unit": "20", "type": "ML" }, "code_information": [ { "code": "00054350049", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN B-12 CYANOCOBALAMIN, UP TO 100 MCG", "drug_information": { "unit": "1000", "type": "GR" }, "code_information": [ { "code": "63323004401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALBUTEIN 5% VIAL 2.5 g/50 mL, P9041 - Infusion, PER 50 ml", "drug_information": { "unit": "50", "type": "ML" }, "code_information": [ { "code": "68516521405", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CORVERT 0.1 MG/ML IV - J1742 per 1 MG", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00009379401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CROFAB INJECTION - J0840 Up to 1 gram", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "50633011012", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DELESTROGEN 40 MG/ML, UP TO 10 MG", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "42023011201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "64980050924", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION", "drug_information": { "unit": "1000", "type": "ML" }, "code_information": [ { "code": "00409792409", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIGIFAB 40 MG INTRAVENOUS SOLUTION", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "50633012011", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIPHENHYDRAMINE 25 MG CAPSULE", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "00904530661", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DOXY-100 100 MG - J3490 INTRAVENOUS SOLUTION", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "63323013011", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FOLIC ACID 5 MG/ML INJECTION SOLUTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "63323018410", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HEPARIN (PORCINE) 20,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "unit": "1000", "type": "F2" }, "code_information": [ { "code": "25021040401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HYDROXYZINE HCL 25 MG TABLET", "drug_information": { "unit": "25", "type": "UN" }, "code_information": [ { "code": "64980016901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3420 - Infuvite Adult 10 mL IV", "drug_information": { "unit": "1000", "type": "GR" }, "code_information": [ { "code": "54643564901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "KETAMINE 50 MG/ML INJECTION SOLUTION", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00143950810", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "00781334209", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GUAIFENESIN 100 MG/5 ML ORAL LIQUID", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "00536082585", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2543 - Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams)", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "55150012030", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PNEUMOVAX 23 25 MCG/0.5 ML INJECTION SOLUTION", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00006494300", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMITRIPTYLINE 10 MG TABLET", "drug_information": { "unit": "10", "type": "UN" }, "code_information": [ { "code": "00603221221", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "RID COMPLETE LICE ELIMINATION KIT 0.5 % SPRAY", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "74300000421", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BANOPHEN ALLERGY 12.5 MG/5 ML ORAL LIQUID", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "49348004537", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3535 - Drug administered through a metered dose inhaler", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00597007575", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MUPIROCIN 2 % TOPICAL OINTMENT", "drug_information": { "unit": "22", "type": "GR" }, "code_information": [ { "code": "45802011222", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE", "code_information": [ { "code": "45381", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1694, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1658, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1553, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 624, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 624, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 624, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 624, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 624, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1783, "minimum": 1783 } ] }, { "description": "COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE (2NDARY)", "code_information": [ { "code": "45381", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 162, "minimum": 162 } ] }, { "description": "BACITRACIN 500 UNIT/GRAM EYE OINTMENT", "drug_information": { "unit": "3.5", "type": "GR" }, "code_information": [ { "code": "00574402235", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BACITRACIN ZINC 500 UNIT/GRAM TOPICAL PACKET", "drug_information": { "unit": "0.9", "type": "GR" }, "code_information": [ { "code": "00168011109", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "17478051002", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROPARACAINE 0.5 % EYE DROPS", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "24208073006", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MIRTAZAPINE 15 MG TABLET", "drug_information": { "unit": "15", "type": "UN" }, "code_information": [ { "code": "51079008620", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "150", "type": "ML" }, "code_information": [ { "code": "00093415080", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LIDOCAINE 20 MG/ML (2 %) INJECTION SOLUTION", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "00409132305", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM", "drug_information": { "unit": "15", "type": "GR" }, "code_information": [ { "code": "00472016315", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CHLORIDE; URINE", "code_information": [ { "code": "82436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "POTASSIUM; URINE", "code_information": [ { "code": "84133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "SODIUM; URINE", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "CLOTRIMAZOLE 1% CREAM 1 ea, 15 g", "drug_information": { "unit": "15", "type": "GR" }, "code_information": [ { "code": "45802043401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SM ANTI-ITCH 2% CREAM 1 ea, 28.4 g", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "49348085472", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL OINTMENT", "drug_information": { "unit": "15", "type": "GR" }, "code_information": [ { "code": "45802004935", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT", "drug_information": { "unit": "3.5", "type": "GR" }, "code_information": [ { "code": "24208079535", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "59762312001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN B1 (THIAMINE), PLASMA/SERUM, LC/MS/MS", "code_information": [ { "code": "84425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 269, "minimum": 269 } ] }, { "description": "LIQUITEARS 1.4 % DROPS 15 mL, 15 mL", "drug_information": { "unit": "15", "type": "UN" }, "code_information": [ { "code": "00904649235", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "TOBRADEX 0.3 %-0.1 % EYE OINTMENT", "drug_information": { "unit": "2.5", "type": "ML" }, "code_information": [ { "code": "61314064725", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SURGICAL FACE MASKS", "code_information": [ { "code": "0271", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 10, "minimum": 10 } ] }, { "description": "ACETYLCYSTEINE 200 MG/ML (30 ML) (20 %) SOLUTION", "drug_information": { "unit": "30", "type": "ML" }, "code_information": [ { "code": "63323069030", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "75", "type": "ML" }, "code_information": [ { "code": "60432006575", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BUPROPION 75 MG TAB", "drug_information": { "unit": "75", "type": "UN" }, "code_information": [ { "code": "23155019101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MIDODRINE 5 MG TAB", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00245021201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BETA-2 MICROGLOBULIN, URINE", "code_information": [ { "code": "82232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "GLYCOSAMINOGLYCANS", "code_information": [ { "code": "83864", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 107, "minimum": 107 } ] }, { "description": "LIPOPROTEIN FRACTIONATION, NMR WITH LIPID PANEL (TRIGLYCERIDES/HDL-C)", "code_information": [ { "code": "83704", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 215, "minimum": 215 } ] }, { "description": "CARDIO IQ NT PROBNP", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "CYTOMEGALOVIRUS (CMV) GENOTYPE", "code_information": [ { "code": "87910", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 565, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 529, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 607, "minimum": 607 } ] }, { "description": "TOXOCARA ANTIBODY, ELISA, SERUM", "code_information": [ { "code": "86682", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "ATROPINE 1 % EYE OINTMENT", "drug_information": { "unit": "3.5", "type": "GR" }, "code_information": [ { "code": "24208082555", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CIPROFLOXACIN 0.3 % EYE DROPS", "drug_information": { "unit": "2.5", "type": "ML" }, "code_information": [ { "code": "61314065625", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SARS-COV-2 SEROLOGY (COVID-19) ANTIBODY (IGG), IMMUNOASSAY", "code_information": [ { "code": "86769", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 240, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 240, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 240, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 253, "minimum": 253 } ] }, { "description": "J1815 - INJECTION, LANTUS INSULIN PER PEN, (PER 5 UNITS???)", "drug_information": { "unit": "100", "type": "F2" }, "code_information": [ { "code": "00088221905", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NEO-SYNEPHRINE (PHENYLEPHRINE) 0.5 % NASAL SPRAY", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "69536005015", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OFLOXACIN 0.3 % EAR DROPS", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "60505036301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROTEIN, TOTAL, 24-HOUR URINE WITH CREATININE", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "VMA (VANILLYLMANDELIC ACID), 24-HOUR URINE", "code_information": [ { "code": "84585", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 215, "minimum": 215 } ] }, { "description": "PROCALCITONIN", "code_information": [ { "code": "84145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 129, "minimum": 129 } ] }, { "description": "ALPHA-1-ACID GLYCOPROTEIN", "code_information": [ { "code": "82985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "FECAL GLOBIN BY IMMUNOCHEMISTRY (INSURE)", "code_information": [ { "code": "82274", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "LEGAL BLOOD ALCOHOL NHP (AFTER HOURS)", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "PROTEIN ELECTROPHORESIS, 24-HOUR URINE (UPEP) 3", "code_information": [ { "code": "84166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "CHANGE OF GASTROSTOMY TUB", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "CHANGE OF GASTROSTOMY TUB", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "CHANGE OF GASTROSTOMY TUBE", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "US ST JOINT LIMITED", "code_information": [ { "code": "76881", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "IMMUNOFIXATION (IFE), URINE", "code_information": [ { "code": "86335", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 70, "minimum": 70 } ] }, { "description": "PHARMACOGENOMICS PANEL", "code_information": [ { "code": "81225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1176, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1350, "minimum": 1350 } ] }, { "description": "HEREDITARY COMPREHENSIVE CANCER PANEL", "code_information": [ { "code": "81432", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4655, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4655, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4655, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4557, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4268, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1715, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1715, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1715, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1715, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1715, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4900, "minimum": 4900 } ] }, { "description": "JAK2 EXON 12, 13, 14 AND 15 MUTATION ANALYSIS", "code_information": [ { "code": "81403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 641, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 628, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 588, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 675, "minimum": 675 } ] }, { "description": "CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION", "drug_information": { "unit": "100", "type": "ML" }, "code_information": [ { "code": "00093417773", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CATECHOLAMINES, FRACTIONATED, 24-HOUR URINE WITH CREATININE", "code_information": [ { "code": "82384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 186, "minimum": 186 } ] }, { "description": "OXALIC ACID, 24-HOUR URINE (W/O CREATININE)", "code_information": [ { "code": "83945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "USTEKINUMAB AND ANTI-USTEKINUMAB ANTIBODY", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 558, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 600, "minimum": 600 } ] }, { "description": "CLOSTRIDIUM DIFFICILE TOXIN GENE, NAA", "code_information": [ { "code": "87493", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 187, "minimum": 187 } ] }, { "description": "BRCA1 AND BRCA2 COMPREHENSIVE ANALYSIS", "code_information": [ { "code": "81162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3348, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3600, "minimum": 3600 } ] }, { "description": "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP", "drug_information": { "unit": "10", "type": "ML" }, "code_information": [ { "code": "24208063562", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT", "drug_information": { "unit": "15", "type": "GR" }, "code_information": [ { "code": "00168005615", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OVA AND PARASITES, CONCENTRATE AND PERMANENT SMEAR, 2 SPECIMENS", "code_information": [ { "code": "87177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "OVA AND PARASITES, CONCENTRATE AND PERMANENT SMEAR, 3 SPECIMENS", "code_information": [ { "code": "87177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 197, "minimum": 197 } ] }, { "description": "YEAST IDENTIFICATION", "code_information": [ { "code": "87106", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 270, "minimum": 270 } ] }, { "description": "BACTERIAL ID AND SUSCEPTIBILITY, AEROBIC", "code_information": [ { "code": "87077", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "ENDOMYSIAL ANTIBODY SCREEN (IGA)", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 64, "minimum": 64 } ] }, { "description": "DRESSING, SACRUM ALLEVYN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 20, "minimum": 20 } ] }, { "description": "DRESSING, HEEL ALLEVYN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 30, "minimum": 30 } ] }, { "description": "DNA TESTING COLLECTION CHARGE", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "HYPOGLYCEMIC PANEL, SERUM/PLASMA", "code_information": [ { "code": "80377", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 128, "minimum": 128 } ] }, { "description": "ANCA SCREEN WITH MPO AND PR3,WITH REFLEX TO ANCA TITER", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 433, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 424, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 397, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 456, "minimum": 456 } ] }, { "description": "AUTOIMMUNE HEPATITIS DIAGNOSTIC PANEL", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 130, "minimum": 130 } ] }, { "description": "MYOGLOBIN, URINE -- LABCORP", "code_information": [ { "code": "83874", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 164, "minimum": 164 } ] }, { "description": "MYOGLOBIN, URINE", "code_information": [ { "code": "83874", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 68, "minimum": 68 } ] }, { "description": "VENOUS BLOOD GAS (ISTAT) -- MGGH LAB", "code_information": [ { "code": "82805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "ARTERIAL BLOOD GASES", "code_information": [ { "code": "82803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "HLA TYPING FOR CELIAC DISEASE -- QUEST", "code_information": [ { "code": "81382", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "HLA Class II typing, low resolution (eg, antigen equivalents); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each", "code_information": [ { "code": "81376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "Protein; Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each", "code_information": [ { "code": "84182", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "SYSTEMIC SCLEROSIS(SCLERODERMA)12 ANTIBODIES PANEL 2 -- QUEST", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "SARS-COV-2 RNA, QUALITATIVE REAL-TIME RT-PCR (CPT 87635) (STATE OF NV)", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "STRATIFY JCV ANTIBODY (WITH INDEX) WITH REFLEX TO INHIBIT -- QUEST", "code_information": [ { "code": "86711", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2060, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2060, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2060, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2017, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1889, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2168.8, "minimum": 2168.8 } ] }, { "description": "MATERNAL SERUM AFP -- QUEST", "code_information": [ { "code": "82105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 165, "minimum": 165 } ] }, { "description": "CA 27.29 -- LABCORP", "code_information": [ { "code": "86300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "JAK2 V617F CASCADING REFLEX TO EXON 9,EXON 12,MPL AND CSF -- QUEST", "code_information": [ { "code": "81270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2422, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2422, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2422, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2372, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2221, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 893, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 893, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 893, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 893, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 893, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2550, "minimum": 2550 } ] }, { "description": "FOLATE, RBC -- QUEST", "code_information": [ { "code": "82747", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "BICILLIN L-A 1,200,000 UNIT/2 ML, J0561 - Injection, PER 100,000 units", "drug_information": { "unit": "100000", "type": "UN" }, "code_information": [ { "code": "60793070110", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CALCITONIN SALMON NASAL SPRAY 3.7 ML", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "RAPID PLASMA REAGIN(RPR) TEST WITH REFLEX TO QUANTITATIVE RP -- LABCORP", "code_information": [ { "code": "86592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 160, "minimum": 160 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (82947)", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (83036)", "code_information": [ { "code": "83036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (80061)", "code_information": [ { "code": "80061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (80076)", "code_information": [ { "code": "80076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (82570)", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (82043)", "code_information": [ { "code": "82043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "DIABETES,NEWLY DIAGNOSED AND MONITORING PANEL -- QUEST (82565)", "code_information": [ { "code": "82565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "RETICULOCYTE COUNT -- LABCORP", "code_information": [ { "code": "85045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "ALKALINE PHOSPHATASE ISOENZYMES -- LABCORP (84075)", "code_information": [ { "code": "84075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 71, "minimum": 71 } ] }, { "description": "ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT", "drug_information": { "unit": "3.5", "type": "GR" }, "code_information": [ { "code": "24208091055", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "24208083060", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ZINC PROTOPORPHYRIN (ZPP) -- QUEST", "code_information": [ { "code": "84202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 113, "minimum": 113 } ] }, { "description": "VITAMIN B3 -- QUEST", "code_information": [ { "code": "84591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 264, "minimum": 264 } ] }, { "description": "ERYTHROCYTE PROTOPORPHYRIN (EP) -- QUEST", "code_information": [ { "code": "84202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "STRONTIUM -- QUEST", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 68, "minimum": 68 } ] }, { "description": "VARICELLA-ZOSTER VIRUS, RAPID METHOD, CULTURE -- QUEST", "code_information": [ { "code": "87254", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 207, "minimum": 207 } ] }, { "description": "HYDROXYZINE 50MG/ML VIAL", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "00517560125", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VITAMIN K -- QUEST", "code_information": [ { "code": "36585", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 321, "minimum": 321 } ] }, { "description": "AMIODARONE 150 MG/3 ML, J0282 - INJECTION, PER 30 MG", "drug_information": { "unit": "150", "type": "ML" }, "code_information": [ { "code": "63323061603", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "VIRAL RESPIRATORY, RAPID CULTURE WITH REFLEX -- QUEST", "code_information": [ { "code": "87254", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "CARDIOLIPIN ANTIBODIES(IGG) -- QUEST 7352 -- CPT 86147", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "CARDIOLIPIN ANTIBODIES(IGA) -- QUEST 7352 -- CPT 86147", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "CARDIOLIPIN ANTIBODIES(IGM) -- QUEST 7352 -- CPT 86147", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "DEEP SEA NASAL 0.65 % SPRAY AEROSOL", "drug_information": { "unit": "44", "type": "ML" }, "code_information": [ { "code": "00904386575", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DEXTROSE 5% LACTATED RINGERS IV SOLUTION 1000 ML", "code_information": [ { "code": "J7121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 73, "minimum": 73 } ] }, { "description": "DEXTROSE 5%-LR IV SOLUTION 1 ea, 1000 mL", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "00409792909", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SARS-COV- RNA (COVID-19), QUALITATIVE NAAT -- QUEST", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 225, "minimum": 225 } ] }, { "description": "EGD, FLEXIBLE, TRANSORAL, WITH REMOVAL OF TUMOR(S), POLYP(S) OR OTHER LESION(S) BY SNARE (PRIMARY)", "code_information": [ { "code": "43251", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1221, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1144, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1313, "minimum": 1313 } ] }, { "description": "COVID-19 RNA -- QUEST -- ACCOUNT: 06036, NO CHARGE", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CERVICAL SPINE W/O Contrast", "code_information": [ { "code": "72125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2420, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2369, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2218, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2547, "minimum": 2547 } ] }, { "description": "Cervical Spine W/ Contrast", "code_information": [ { "code": "72126", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2990, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2990, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2990, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2927, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2741, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3147, "minimum": 3147 } ] }, { "description": "Thoracic Spine W/ Contrast", "code_information": [ { "code": "72129", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2753, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2753, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2753, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2695, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2524, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2898, "minimum": 2898 } ] }, { "description": "ELECTROLYTES, FECES -- QUEST 31595 -- CPT 82438", "code_information": [ { "code": "82438", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "ELECTROLYTES, FECES -- QUEST 31595 -- CPT 84311", "code_information": [ { "code": "84311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "ELECTROLYTES, FECES -- QUEST 31595 -- CPT 84302", "code_information": [ { "code": "84302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "COVID-19 RAPID ANTIGEN (MCSO) -- MGGH LAB", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "HYDROCORTISONE 1 % TOPICAL CREAM", "drug_information": { "unit": "1.5", "type": "GR" }, "code_information": [ { "code": "00168015408", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIPHTHERIA TETANUS TOXOIDS \u003c 7 YO", "code_information": [ { "code": "90702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 42, "minimum": 42 } ] }, { "description": "FLUNITRAZEPAM AND METABOLITES, QUANTITATIVE, URINE - QUEST", "code_information": [ { "code": "80346", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 351, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 377, "minimum": 377 } ] }, { "description": "KETAMINE AND METABOLITE SCREEN, URINE -- QUEST", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "FLUNITRAZEPAM AND METABOLITES, QUANTITATIVE -- QUEST", "code_information": [ { "code": "80346", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 316, "minimum": 316 } ] }, { "description": "GAMMA-HYDROXYBUTYRIC ACID SCREEN, SERUM/PLASMA -- QUEST", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 396, "minimum": 396 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 81003", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 82131", "code_information": [ { "code": "82131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 82140", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 82340", "code_information": [ { "code": "82340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 82436", "code_information": [ { "code": "82436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 82507", "code_information": [ { "code": "82507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 82570", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 83735", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 83935", "code_information": [ { "code": "83935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 83945", "code_information": [ { "code": "83945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 84105", "code_information": [ { "code": "84105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 84133", "code_information": [ { "code": "84133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 84300", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 84392", "code_information": [ { "code": "84392", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "KIDNEY STONE URINE TEST (USM24) -- LABCORP -- CPT 84560", "code_information": [ { "code": "84560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "CATECHOLAMINES, FRACTIONED, PLASMA -- QUEST", "code_information": [ { "code": "82384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 227, "minimum": 227 } ] }, { "description": "ALDOSTERONE/PLASMA RENIN ACTIVITY RATIO,LC/MS/MS -- QUEST -- CPT 84244", "code_information": [ { "code": "84244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "ALDOSTERONE/PLASMA RENIN ACTIVITY RATIO, LC/MS/MS -- QUEST -- CPT 82088", "code_information": [ { "code": "82088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "PLASMA RENIN ACTIVITY, LC/MS/MS -- QUEST", "code_information": [ { "code": "84244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 135, "minimum": 135 } ] }, { "description": "OBSERVATION DIRECT ENTRY", "code_information": [ { "code": "G0379", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 71, "minimum": 71 } ] }, { "description": "GOAT\u0027S MILK -- LABCORP", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 61, "minimum": 61 } ] }, { "description": "ALLERGEN PROFILE, FOOD -- LABCORP -- CPT 86003 (EXPLODED)", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 441, "minimum": 441 } ] }, { "description": "TRYPTASE -- LABCORP", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "CASEIN -- LABCORP", "code_information": [ { "code": "86008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "MEAT ALLERGEN -- LABCORP", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 37, "minimum": 37 } ] }, { "description": "BEEF (F27) IGG -- QUEST", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 55, "minimum": 55 } ] }, { "description": "PORK (F26) IGE -- QUEST", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "CHICKEN MEAT (F83) IGE -- QUEST", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "GOAT MILK (F300) IGE -- QUEST", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 30, "minimum": 30 } ] }, { "description": "CASEIN (F78) IGE -- QUEST", "code_information": [ { "code": "86008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 30, "minimum": 30 } ] }, { "description": "CYKLOKAPRON (TRANEXAMIC ACID) 100MG/ML", "drug_information": { "unit": "1", "type": "EA" }, "code_information": [ { "code": "61990061102", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SODIUM CHLORIDE 3 % INTRAVENOUS SOLUTION 500ML", "drug_information": { "unit": "500", "type": "EA" }, "code_information": [ { "code": "00338005403", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AFRIN (OXYMETAZOLINE HCL) 0.05 % NASAL SPRAY", "drug_information": { "unit": "1", "type": "EA" }, "code_information": [ { "code": "00904676130", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHOS-NAK POWD PACK 160-280-250 MG ORAL", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PHOS-NAK PACKET 1 ea, 100 eaches", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "60258000601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "I\u0026D ABSCESS, PERITONSILLAR", "code_information": [ { "code": "42700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "I\u0026D ABSCESS, PERITONSILLAR", "code_information": [ { "code": "42700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "CYTOCHROME P450 2D6 GENOTYPE -- QUEST", "code_information": [ { "code": "81226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 548, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 548, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 548, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 577, "minimum": 577 } ] }, { "description": "BREATHING CIRCUIT WITH AUTO FILL CHAMBER", "code_information": [ { "code": "A4618", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "HIGH FLOW CANNULA", "code_information": [ { "code": "A4615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 40, "minimum": 40 } ] }, { "description": "MAXI VENTURI MUFFLER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "PROSTAGLANDINS, SERUM/PLASMA -- QUEST", "code_information": [ { "code": "84150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 414, "minimum": 414 } ] }, { "description": "HISTAMINE DETERMINATION, WHOLE BLOOD -- LABCORP", "code_information": [ { "code": "83088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 378, "minimum": 378 } ] }, { "description": "ANGIOEDEMA PANEL, HEREDITARY, COMPREHENSIVE -- QUEST -- CPT 86160", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "ANGIOEDEMA PANEL, HEREDITARY, COMPREHENSIVE -- QUEST -- CPT 86161", "code_information": [ { "code": "86161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "HISTAMINE, PLASMA -- QUEST", "code_information": [ { "code": "83088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 206, "minimum": 206 } ] }, { "description": "BETA-2-GLYCOPROTEIN AB (IGG,IGA,IGM) -- QUEST", "code_information": [ { "code": "86146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "CYTOMEGALOVIRUS DNA,QUANTITATIVE,REAL-TIME PCR -- QUEST", "code_information": [ { "code": "87497", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 487, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 447, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 513, "minimum": 513 } ] }, { "description": "EXTERNAL FEMALE CATHETER", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 17.5, "minimum": 17.5 } ] }, { "description": "DECOMPRESSION NEEDLE 14GX3.25\"", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 40, "minimum": 40 } ] }, { "description": "OPTIFOAM 10X9 SACRAL", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 29, "minimum": 29 } ] }, { "description": "CALCIUM ALGINATE 4X4", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 7.5, "minimum": 7.5 } ] }, { "description": "OPIATES, URINE -- QUEST", "code_information": [ { "code": "80361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 167, "minimum": 167 } ] }, { "description": "N-METHYLHISTAMINE, 24 HOUR, URINE -- QUEST -- CPT 82542", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "N-METHYLHISTAMINE, 24 HOUR, URINE -- QUEST -- CPT 82570", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 208, "minimum": 208 } ] }, { "description": "OXYCODONE SCREEN AND CONFIRMATION, URINE -- QUEST", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 379, "minimum": 379 } ] }, { "description": "2, 3-DINOR-11 BETA-PROSTAGLANDIN F2 ALPHA, URINE -- QUEST", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 397, "minimum": 397 } ] }, { "description": "ASPIRIN SUPP 600 MG", "drug_information": { "unit": "600", "type": "UN" }, "code_information": [ { "code": "00574703612", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BIORPHEN 0.5 MG/5 ML AMPULE 500 mcg, 5 mL", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "71863020206", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LORAZEPAM INTENSOL ORAL 2MG/ML", "drug_information": { "unit": "2", "type": "GR" }, "code_information": [ { "code": "00054353244", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MORPHINE ORAL 10MG/5ML", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00054023749", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ETOMIDATE INJECTION 20MG/10ML", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "00143950610", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NICOTINE TRANSDERMAL PATCH", "drug_information": { "unit": "7", "type": "GR" }, "code_information": [ { "code": "70677003101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "US GUIDANCE FOR VASCULAR ACCESS", "code_information": [ { "code": "76937", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 300, "minimum": 300 } ] }, { "description": "HERPES SIMPLEX VIRUS, TYPE 1 AND 2 DNA, QUALITATIVE, REAL TIME -- QUEST -- CPT 87520", "code_information": [ { "code": "87520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 219, "minimum": 219 } ] }, { "description": "CYTOMEGALOVIRUS AB (IGM) -- QUEST", "code_information": [ { "code": "86645", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "FOOD SPECIFIC IGG ALLERGY PANEL 2 - QUEST 37334", "code_information": [ { "code": "86001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 909, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 909, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 909, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 890, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 957, "minimum": 957 } ] }, { "description": "CHEST, Low Dose, W/O CONTRAST", "code_information": [ { "code": "71271", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1733, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1733, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1733, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1696, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1589, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 638, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 638, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 638, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 638, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 638, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1824, "minimum": 1824 } ] }, { "description": "CYCLOSPORA AND ISOSPORA EXAMINATION -- QUEST-- CPT 87015", "code_information": [ { "code": "87015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "CYCLOSPORA AND ISOSPORA EXAMINATION -- QUEST -- CPT 87207", "code_information": [ { "code": "87207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 27, "minimum": 27 } ] }, { "description": "ALBUMIN 25% 12.5 GRAMS/50 ML, P9047 - Infusion, PER 50 ML", "drug_information": { "unit": "50", "type": "ML" }, "code_information": [ { "code": "44206025105", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J0878 - Injection, daptomycin, 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00409593301", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SPLINT, ELASTIC ANKLE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8, "minimum": 8 } ] }, { "description": "METHYLENETETRAHYDROFOLATE REDUCTASE(MTHFR), DNA MUTATION ANALYSIS - QUEST", "code_information": [ { "code": "81291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 465, "minimum": 465 } ] }, { "description": "INSERTION OF PICC WITH IMAGING, AGE 5 OR OLDER", "code_information": [ { "code": "36573", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1176, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1350, "minimum": 1350 } ] }, { "description": "DRESSING, SORBA VIEW PICC LINE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 10, "minimum": 10 } ] }, { "description": "BIOPATCH DISC 1\" 7MM CTI PICC LINE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "STATLOC PICCPLUS DEVICE PICC LINE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 20, "minimum": 20 } ] }, { "description": "CLOTH, CHLORHEXIDINE PICC LINE", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6, "minimum": 6 } ] }, { "description": "INTRAORAL I\u0026D OF ABSCESS, CYST, OR HEMATOMA TONGUE AND MOUTH", "code_information": [ { "code": "41008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 558, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 600, "minimum": 600 } ] }, { "description": "DIHYDROPYRIMIDINE DEHYDROGENASE (DPD) GENE MUTATION ANALYSIS -- QUEST", "code_information": [ { "code": "81232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "VEKLURY (REMDESIVIR) 100 MG IV", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "61958290102", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PLATELET PHORESIS, 1 UNIT", "code_information": [ { "code": "P9034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 886, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 886, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 886, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 868, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 813, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 933, "minimum": 933 } ] }, { "description": "PLATELET PHORESIS, 2 OR MORE UNITS", "code_information": [ { "code": "P9034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1617, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1617, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1617, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1583, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1482, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1702, "minimum": 1702 } ] }, { "description": "CLOSED TREATMENT OF KNEE DISLOCATION: WITHOUT ANESTHESIA", "code_information": [ { "code": "27550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 521, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 477, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 548, "minimum": 548 } ] }, { "description": "PREDNISONE 5 MG TABLET", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00054472825", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HEMOGLOBINOPATHY EVALUATION (HEMOGLOBIN FRACTIONATION) -- QUEST -- CPT 83020", "code_information": [ { "code": "83020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "HEMOGLOBINOPATHY EVALUATION (HEMOGLOBIN FRACTIONATION) -- QUEST -- CPT 85014", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "HEMOGLOBINOPATHY EVALUATION (HEMOGLOBIN FRACTIONATION) -- QUEST -- CPT 85018", "code_information": [ { "code": "85018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "HEMOGLOBINOPATHY EVALUATION (HEMOGLOBIN FRACTIONATION) -- QUEST -- CPT 85041", "code_information": [ { "code": "85041", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 15, "minimum": 15 } ] }, { "description": "NEUPOGEN 300 MG/0.5ML INJ", "code_information": [ { "code": "J1442", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 653, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 750, "minimum": 750 } ] }, { "description": "Neupogen 300 MCG/0.5 ML SYR 300 mg, 0.5 mL", "drug_information": { "unit": "300", "type": "GR" }, "code_information": [ { "code": "55513092491", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MRI NO SHOW", "code_information": [ { "code": "0610", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "PROTEIN ELECTROPHORESIS,WITH TOTAL PROTEIN AND REFLEX TO IFE, URINE -- QUEST -- CPT 82570", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 5, "minimum": 5 } ] }, { "description": "PROTEIN ELECTROPHORESIS,WITH TOTAL PROTEIN AND REFLEX TO IFE, URINE -- QUEST -- CPT 84156", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 5, "minimum": 5 } ] }, { "description": "PROTEIN ELECTROPHORESIS,WITH TOTAL PROTEIN AND REFLEX TO IFE, URINE -- QUEST -- CPT 84166", "code_information": [ { "code": "84166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 5, "minimum": 5 } ] }, { "description": "VIGAMOX 0.5 % EYE DROPS", "drug_information": { "unit": "3", "type": "ML" }, "code_information": [ { "code": "00065401303", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LIDOCAINE 5% PATCH 700MG", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4, "minimum": 4 } ] }, { "description": "ALLERGY EVALUATION 8,ARID SOUTHWEST -- CPT 86003 X10", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 305, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 350, "minimum": 350 } ] }, { "description": "LIDOCAINE 5% PATCH 1 ea, 30 eaches", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "42858011830", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "REGULAR INSULIN (HUMULIN-R), J1815 - INJECTION, PER 5 UNITS", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00002821517", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NO SHOW FEE", "code_information": [ { "code": "0509", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "NO SHOW PHYSICAL THERAPY", "code_information": [ { "code": "0422", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "DRAINAGE OF ABSCESS, CYST, HEATOMA FROM DENTOALVEOLAR STRUCTURES", "code_information": [ { "code": "41800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 653, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 750, "minimum": 750 } ] }, { "description": "ZINC SULFATE 220 MG (50 MG) CAPSULE", "drug_information": { "unit": "50", "type": "UN" }, "code_information": [ { "code": "00904533260", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OXIMETRY", "code_information": [ { "code": "94760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 108, "minimum": 108 } ] }, { "description": "INCENTIVE SPIROMETERY TX", "code_information": [ { "code": "94727", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "OXYGEN PER HOUR", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 28, "minimum": 28 } ] }, { "description": "PFT MINING SCREEN", "code_information": [ { "code": "94010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 125, "minimum": 125 } ] }, { "description": "ECHOCARDIOGRAM, COMPLETE", "code_information": [ { "code": "93306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2060, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 828, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2365, "minimum": 2365 } ] }, { "description": "CTA CHEST WO/W CONTR W/IMAGE", "code_information": [ { "code": "71275", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3074, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3074, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3074, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3009, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2819, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3236, "minimum": 3236 } ] }, { "description": "BRAIN WO/W CONTR MRI", "code_information": [ { "code": "70553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3919, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3919, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3919, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3836, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3593, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1444, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1444, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1444, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1444, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1444, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4125, "minimum": 4125 } ] }, { "description": "HEAD W/O CONTRAST", "code_information": [ { "code": "70450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1688, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1581, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1815, "minimum": 1815 } ] }, { "description": "UE RT JOINT WO CONTRAST", "code_information": [ { "code": "73221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2836, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2836, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2836, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2776, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2600, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2985, "minimum": 2985 } ] }, { "description": "LE RT JNT WO CONTR", "code_information": [ { "code": "73721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2404, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2252, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2585, "minimum": 2585 } ] }, { "description": "CTA ABD WO/W CONTRAST W/IMAG", "code_information": [ { "code": "74175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3448, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3229, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3707, "minimum": 3707 } ] }, { "description": "BRAIN WO CONTRAST MRI", "code_information": [ { "code": "70551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2483, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2483, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2483, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2431, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2277, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2614, "minimum": 2614 } ] }, { "description": "NECK SOFT TISSUE W C", "code_information": [ { "code": "70491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2404, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2252, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2585, "minimum": 2585 } ] }, { "description": "CHEST WITH CONTRAST", "code_information": [ { "code": "71260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2406, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2406, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2406, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2356, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2533, "minimum": 2533 } ] }, { "description": "LE LT JOINT WO CONTR", "code_information": [ { "code": "73721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2404, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2252, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 905, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2585, "minimum": 2585 } ] }, { "description": "NECK WO/W CONTRAST", "code_information": [ { "code": "70492", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2803, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2803, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2803, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2744, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2570, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1033, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1033, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1033, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1033, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1033, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2951, "minimum": 2951 } ] }, { "description": "UE LT JNT WO CONTR", "code_information": [ { "code": "73221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2836, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2836, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2836, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2776, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2600, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2985, "minimum": 2985 } ] }, { "description": "PELVIS NON OB ULTRA SOUND", "code_information": [ { "code": "76856", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 772, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 830, "minimum": 830 } ] }, { "description": "XR--SPINE.LUMBAR--VIEWS 5", "code_information": [ { "code": "72110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 617, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 663, "minimum": 663 } ] }, { "description": "CHEST W/O CONTRAST", "code_information": [ { "code": "71250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1751, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1640, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 659, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 659, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 659, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 659, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 659, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1883, "minimum": 1883 } ] }, { "description": "CHEST WO/W CONTRAST", "code_information": [ { "code": "71270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2712, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2540, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1021, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1021, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1021, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1021, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1021, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2916, "minimum": 2916 } ] }, { "description": "ABDOMEN MRI", "code_information": [ { "code": "74181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3060, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2866, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3290, "minimum": 3290 } ] }, { "description": "CT--ABDOMEN PELVIS WO/W IV", "code_information": [ { "code": "74178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4411, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 4131, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1660, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1660, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1660, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1660, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1660, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4743, "minimum": 4743 } ] }, { "description": "L SPINE WO/W CONTR MRI", "code_information": [ { "code": "72158", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3918, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3918, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3918, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3835, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3592, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4124, "minimum": 4124 } ] }, { "description": "S.T. BACK", "code_information": [ { "code": "76800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1506, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1474, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1381, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1585, "minimum": 1585 } ] }, { "description": "LOWER EXTREMITY LT W/O C", "code_information": [ { "code": "73700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1995, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1995, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1995, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1953, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1829, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2100, "minimum": 2100 } ] }, { "description": "LOWER EXTREMITY RT W/O C", "code_information": [ { "code": "73700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1995, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1995, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1995, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1953, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1829, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2100, "minimum": 2100 } ] }, { "description": "NECK SOFT TISSUE W/O C", "code_information": [ { "code": "70490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2075, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2075, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2075, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2031, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1902, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 764, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 764, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 764, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 764, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 764, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2184, "minimum": 2184 } ] }, { "description": "UNI DUPLEX LOW EXT LT ARTERY", "code_information": [ { "code": "93926", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 907, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1041, "minimum": 1041 } ] }, { "description": "MRI ORBITS FACE NECK W/WO", "code_information": [ { "code": "70543", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4305, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4215, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3947, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1586, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4532, "minimum": 4532 } ] }, { "description": "ABD MRI WO/W CONTRAST", "code_information": [ { "code": "74183", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4301, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4301, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4301, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 4210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3943, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1584, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1584, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1584, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1584, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1584, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4527, "minimum": 4527 } ] }, { "description": "XR--SPINE.LUMBAR--VIEWS 2 OR 3", "code_information": [ { "code": "72100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "T SPINE WO/W CONTR MRI", "code_information": [ { "code": "72157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3882, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3882, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3882, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3800, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3559, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1430, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1430, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1430, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1430, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1430, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4086, "minimum": 4086 } ] }, { "description": "UNI DUPLEX LOW EXT RT ARTERY", "code_information": [ { "code": "93926", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 907, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1041, "minimum": 1041 } ] }, { "description": "PELVIS W CONTRAST", "code_information": [ { "code": "72193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2638, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2638, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2638, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2583, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2419, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 972, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 972, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 972, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 972, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 972, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2777, "minimum": 2777 } ] }, { "description": "UPPER EXTREMITY LT W/O C", "code_information": [ { "code": "73200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1895, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1895, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1895, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1855, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1738, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1995, "minimum": 1995 } ] }, { "description": "C SPINE WO/W CONTR MRI", "code_information": [ { "code": "72156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3918, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3918, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3918, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3835, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3592, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1443, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4124, "minimum": 4124 } ] }, { "description": "THORACIC SPINE W/O Contrast", "code_information": [ { "code": "72128", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2332, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2283, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2455, "minimum": 2455 } ] }, { "description": "MRA HEAD WO/W CONTR COW", "code_information": [ { "code": "70546", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 4078, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 4078, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 4078, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3992, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3739, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1503, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1503, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1503, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1503, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1503, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 4293, "minimum": 4293 } ] }, { "description": "ABDOMEN WITH CONTRAST", "code_information": [ { "code": "74160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2408, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2408, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2408, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2358, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2208, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2535, "minimum": 2535 } ] }, { "description": "CT ANGIO HEAD ARTERIES W/ CONTRAST", "code_information": [ { "code": "70496", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2966, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2966, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2966, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2903, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2719, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1093, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1093, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1093, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1093, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1093, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3122, "minimum": 3122 } ] }, { "description": "XR--SACRUM+COCCYX--VIEWS", "code_information": [ { "code": "72220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 451, "minimum": 451 } ] }, { "description": "RENAL DOPPLER US - LIMITED", "code_information": [ { "code": "93976", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2463, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2463, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2463, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2411, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2259, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 908, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 908, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 908, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 908, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 908, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2593, "minimum": 2593 } ] }, { "description": "XR--RADIUS.LEFT+ULNA.LEFT--VIEWS 2", "code_information": [ { "code": "73090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 354, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 381, "minimum": 381 } ] }, { "description": "LOWER EXTREMITY LT W C", "code_information": [ { "code": "73701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2604, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2439, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2800, "minimum": 2800 } ] }, { "description": "MRI ORBITS FACE/NECK WO", "code_information": [ { "code": "70540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2810, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2810, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2810, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2751, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2576, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1035, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1035, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1035, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1035, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1035, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2958, "minimum": 2958 } ] }, { "description": "LOWER EXTREMITY RT W C", "code_information": [ { "code": "73701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2604, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2439, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2800, "minimum": 2800 } ] }, { "description": "SCROTUM ULTRASOUND", "code_information": [ { "code": "76870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 736, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 736, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 736, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 721, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 675, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 775, "minimum": 775 } ] }, { "description": "TRANSVAGINAL OB U/S", "code_information": [ { "code": "76817", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 620, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 620, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 620, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 607, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 569, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 653, "minimum": 653 } ] }, { "description": "RIGHT UE ARTERIAL", "code_information": [ { "code": "93931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 848, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 794, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 912, "minimum": 912 } ] }, { "description": "MRA NECK WO (CAROTIDS)", "code_information": [ { "code": "70547", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2571, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2408, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 968, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2765, "minimum": 2765 } ] }, { "description": "XR--RADIUS.RIGHT+ULNA.RIGHT--VIEWS 2", "code_information": [ { "code": "73090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 354, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 381, "minimum": 381 } ] }, { "description": "MAXILLOFACIAL WO/W CONTR", "code_information": [ { "code": "70488", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2823, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2823, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2823, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2764, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2589, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1040, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1040, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1040, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1040, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1040, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2972, "minimum": 2972 } ] }, { "description": "LUMBAR SPINE W/O Contrast", "code_information": [ { "code": "72131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2169, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2031, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 816, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 816, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 816, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 816, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 816, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2332, "minimum": 2332 } ] }, { "description": "MRA HEAD WO CONT COW", "code_information": [ { "code": "70544", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2335, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2511, "minimum": 2511 } ] }, { "description": "LEFT UE ARTERIAL", "code_information": [ { "code": "93931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 848, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 794, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 912, "minimum": 912 } ] }, { "description": "LOWER EXTREMITY RT WO/W CONTR", "code_information": [ { "code": "73702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2939, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2939, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2939, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2877, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2695, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3094, "minimum": 3094 } ] }, { "description": "LOWER EXTREMITY LT WO/W CONTR", "code_information": [ { "code": "73702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2939, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2939, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2939, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2877, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2695, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3094, "minimum": 3094 } ] }, { "description": "XR--PELVIS--VIEWS AP \u0026 LATERAL", "code_information": [ { "code": "72170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 345, "minimum": 345 } ] }, { "description": "UPPER EXTREMITY RT W/O C", "code_information": [ { "code": "73200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1895, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1895, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1895, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1855, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1738, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1995, "minimum": 1995 } ] }, { "description": "MAXILLOFACIAL W CONTRAST", "code_information": [ { "code": "70487", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2024, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2024, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2024, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1981, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1855, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2130, "minimum": 2130 } ] }, { "description": "T SPINE 2 VIEWS (TSPINE ONLY)", "code_information": [ { "code": "72070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 412, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 404, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 378, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 434, "minimum": 434 } ] }, { "description": "XR--RIBS.RIGHT--VIEWS 2", "code_information": [ { "code": "71100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 374, "minimum": 374 } ] }, { "description": "XR--XXX BONES--VIEWS SURVEY", "code_information": [ { "code": "77074", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 790, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 740, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 850, "minimum": 850 } ] }, { "description": "XR--RIBS.BILATERAL--VIEWS 4", "code_information": [ { "code": "71111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 778, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 778, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 778, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 762, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 819, "minimum": 819 } ] }, { "description": "XR--RIBS.LEFT--VIEWS 2", "code_information": [ { "code": "71100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 374, "minimum": 374 } ] }, { "description": "XR--RIBS.BILATERAL--VIEWS 3", "code_information": [ { "code": "71110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 405, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 465, "minimum": 465 } ] }, { "description": "XR--CLAVICLE.LEFT--VIEWS", "code_information": [ { "code": "73000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 362, "minimum": 362 } ] }, { "description": "XR--SCAPULA.RIGHT--VIEWS", "code_information": [ { "code": "73010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 352, "minimum": 352 } ] }, { "description": "CT Lumbar W/ Contrast", "code_information": [ { "code": "72132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2875, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2875, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2875, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2814, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2636, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1059, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1059, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1059, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1059, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1059, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3026, "minimum": 3026 } ] }, { "description": "XR--CLAVICLE.RIGHT--VIEWS", "code_information": [ { "code": "73000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 362, "minimum": 362 } ] }, { "description": "EXTREMITY, NON-VASCULAR, LIMITED U/S", "code_information": [ { "code": "76882", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 517, "minimum": 517 } ] }, { "description": "SWALLOW TREATMENT-15 MIN", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 339, "minimum": 339 } ] }, { "description": "PARAFFIN BATH", "code_information": [ { "code": "97018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 99, "minimum": 99 } ] }, { "description": "SPEECH-GROUP", "code_information": [ { "code": "92508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 228, "minimum": 228 } ] }, { "description": "SELFCARE HOME MGMT TRNG", "code_information": [ { "code": "97535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 113, "minimum": 113 } ] }, { "description": "P/T RE-EVAL EST PLAN CARE (FM)", "code_information": [ { "code": "97164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 106, "minimum": 106 } ] }, { "description": "TRACTION MANUAL THER TEC", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 103, "minimum": 103 } ] }, { "description": "REPAIR SUP WOUNDS \u003c2.5CM*", "code_information": [ { "code": "12001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 334, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 384, "minimum": 384 } ] }, { "description": "CONTROL NASAL HEMMOR SMP*", "code_information": [ { "code": "30901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 365, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 342, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 393, "minimum": 393 } ] }, { "description": "REPAIR WOUND 2.6-7.5 CM", "code_information": [ { "code": "12002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 413, "minimum": 413 } ] }, { "description": "CTR NASAL HEMMOR.PACK/CA*", "code_information": [ { "code": "30905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 514, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 514, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 514, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 471, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 541, "minimum": 541 } ] }, { "description": "IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS", "code_information": [ { "code": "96523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS", "code_information": [ { "code": "10120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 273, "minimum": 273 } ] }, { "description": "COMPLETE BLOOD COUNT (CBC)", "code_information": [ { "code": "85025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 136, "minimum": 136 } ] }, { "description": "COMPLETE METABOLIC PANEL (CMP)", "code_information": [ { "code": "80053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 196, "minimum": 196 } ] }, { "description": "TROPONIN", "code_information": [ { "code": "84484", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 213, "minimum": 213 } ] }, { "description": "BNP", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 312, "minimum": 312 } ] }, { "description": "TSH", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "GLYCOHEMOGLOBIN", "code_information": [ { "code": "83036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 130, "minimum": 130 } ] }, { "description": "URINE CULTURE", "code_information": [ { "code": "87086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 134, "minimum": 134 } ] }, { "description": "BLOOD CULTURE", "code_information": [ { "code": "87040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "BASIC METABOLIC PANEL (BMP)", "code_information": [ { "code": "80048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 165, "minimum": 165 } ] }, { "description": "LIPID PANEL", "code_information": [ { "code": "80061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 175, "minimum": 175 } ] }, { "description": "FLU TEST", "code_information": [ { "code": "87804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 162, "minimum": 162 } ] }, { "description": "VENIPUNCTURE", "code_information": [ { "code": "36415", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 36, "minimum": 36 } ] }, { "description": "PTH, INTACT WITHOUT CALCIUM", "code_information": [ { "code": "83970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 397, "minimum": 397 } ] }, { "description": "LACTIC ACID (IN-HOUSE)", "code_information": [ { "code": "83605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 157, "minimum": 157 } ] }, { "description": "MAGNESIUM", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "FREE TESTOSTERONE", "code_information": [ { "code": "84402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 240, "minimum": 240 } ] }, { "description": "IRON BINDING CAPACITY", "code_information": [ { "code": "83550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 99, "minimum": 99 } ] }, { "description": "PSA SCREEN", "code_information": [ { "code": "G0103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 155, "minimum": 155 } ] }, { "description": "FREE T4", "code_information": [ { "code": "84439", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 148, "minimum": 148 } ] }, { "description": "HCG QUAL URINE", "code_information": [ { "code": "81025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "PHOSPHORUS INORGANIC", "code_information": [ { "code": "84100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "H. PYLORI", "code_information": [ { "code": "86677", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 147, "minimum": 147 } ] }, { "description": "HCG QUAL SERUM", "code_information": [ { "code": "81025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 107, "minimum": 107 } ] }, { "description": "HEPATITIS B CORE ANTIBODY, TOTAL", "code_information": [ { "code": "86704", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "URIC ACID", "code_information": [ { "code": "84550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 74, "minimum": 74 } ] }, { "description": "AMYLASE", "code_information": [ { "code": "82150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "HEPATITIS B SURFACE ANTIGEN WITH RELEX CONFIRMATION", "code_information": [ { "code": "87340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "KETONES", "code_information": [ { "code": "82009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "SED RATE (ESR)", "code_information": [ { "code": "85651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 72, "minimum": 72 } ] }, { "description": "DIGOXIN", "code_information": [ { "code": "80162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 163, "minimum": 163 } ] }, { "description": "BONE DENSITY SPINE ONLY", "code_information": [ { "code": "77078", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 327, "minimum": 327 } ] }, { "description": "IBANDRONATE INJ 3MG/3ML", "drug_information": { "unit": "3", "type": "GR" }, "code_information": [ { "code": "67457052433", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SELENIUM -- QUEST", "code_information": [ { "code": "84255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 157.84, "minimum": 157.84 } ] }, { "description": "FACTOR II ACTIVITY, CLOTTING -- QUEST", "code_information": [ { "code": "85210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 141, "minimum": 141 } ] }, { "description": "VITAMIN B COMPLEX + FOLIC", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "30768000601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PREGABALIN 150MG CAP", "drug_information": { "unit": "150", "type": "GR" }, "code_information": [ { "code": "62332012390", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HERPES SIMPLEX VIRUS/VARICELLA-ZOSTER VIRUS, RAPID CULTURE", "code_information": [ { "code": "87254", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 315, "minimum": 315 } ] }, { "description": "EXCISE,LESION,\u003e4.0CM", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 374, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 343, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 394, "minimum": 394 } ] }, { "description": "LAYER CLOSURE 2.6-7.5 CM", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE WITH MANIPULATION", "code_information": [ { "code": "27810", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 651, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 610, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 700, "minimum": 700 } ] }, { "description": "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE WITH MANIPULATION", "code_information": [ { "code": "27810", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 589, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 589, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 589, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 620, "minimum": 620 } ] }, { "description": "ABDOMINAL PARACENTESIS WITH IMAGING GUIDANCE", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 869, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 869, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 869, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 851, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 797, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 320, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 320, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 320, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 320, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 320, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 915, "minimum": 915 } ] }, { "description": "PRIMIDONE AND PHENOBARBITAL - QUEST - CPT 80184", "code_information": [ { "code": "80184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "PRIMIDONE AND PHENOBARBITAL - QUEST - CPT 80188", "code_information": [ { "code": "80188", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)", "code_information": [ { "code": "46600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "EXCISE, LESION 1.1-2.0 CM", "code_information": [ { "code": "11402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "VITAMIN C -- QUEST", "code_information": [ { "code": "82180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 134, "minimum": 134 } ] }, { "description": "LEGAL BLOOD ALCOHOL (AFTER HOURS)", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 250, "minimum": 250 } ] }, { "description": "CEFDINIR 300 MG CAP", "drug_information": { "unit": "300", "type": "GR" }, "code_information": [ { "code": "16714039102", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "QUETIAPINE FUMARATE 25 MG TAB", "drug_information": { "unit": "25", "type": "GR" }, "code_information": [ { "code": "16714045201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFDINIR 250MG/5ML SUSPENSION", "drug_information": { "unit": "250", "type": "ML" }, "code_information": [ { "code": "65862021960", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "DIRECT ANTIGLOBULIN TEST (DAT)-- QUEST", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "Evaluation of speech fluency (eg, stuttering, cluttering)", "code_information": [ { "code": "92521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 400, "minimum": 400 } ] }, { "description": "Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)", "code_information": [ { "code": "92522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 340, "minimum": 340 } ] }, { "description": "XR--FINGER.THIRD.LEFT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "XR--FINGER.FOURTH.LEFT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "XR--FINGER.FIFTH.LEFT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "XR--FINGER.THIRD.RIGHT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "XR--FINGER.FOURTH.RIGHT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "XR--FINGER.FIFTH.RIGHT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 301, "minimum": 301 } ] }, { "description": "HEAVY METALS PANEL, RANDOM URINE -- QUEST -- CPT 82175", "code_information": [ { "code": "82175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "HEAVY METALS PANEL, RANDOM URINE -- QUEST -- CPT 83655", "code_information": [ { "code": "83655", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "HEAVY METALS PANEL, RANDOM URINE -- QUEST -- CPT 83825", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "HEAVY METALS PANEL, RANDOM URINE -- QUEST -- CPT 82570", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "HPV DNA (HIGH RISK)", "code_information": [ { "code": "87623", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "PLA2R ANTIBODY PANEL -- QUEST -- CPT 83520", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 133, "minimum": 133 } ] }, { "description": "DRUGS OF ABUSE SCREEN (DAU), DRUG SCREEN CLINIC", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "PERICARDIOCENTESIS, INCLUDING IMAGING GUIDE, WHEN PERFORMED, PROFEE", "code_information": [ { "code": "33016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 362, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 354, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 381, "minimum": 381 } ] }, { "description": "MERCURY, URINE -- QUEST", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "MERCURY, SERUM -- QUEST", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "MERCURY, URINE, GRC-QUEST", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "MERCURY, SERUM, GRC-QUEST", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "MILK COMPONENT PANEL", "code_information": [ { "code": "86008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 32, "minimum": 32 } ] }, { "description": "TRIMMING OF DYSTOPHIC NAILS, ANY NUMBER", "code_information": [ { "code": "G0127", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 30, "minimum": 30 } ] }, { "description": "CERVICAL COLLAR FOAM", "code_information": [ { "code": "L0120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "MONKEYPOX VIRUS DNA, PCR", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "SOC - CHEST X-RAY PA AND LATERAL", "code_information": [ { "code": "77299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "LEUKEMIA/LYMPHONA EVALUATION", "code_information": [ { "code": "88184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "XR--CHEST, 1 VIEW -- MINE CONTRACT PRICING", "code_information": [ { "code": "71045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "URINE MICRO", "code_information": [ { "code": "81015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 60, "minimum": 60 } ] }, { "description": "VENOFER IRON SUCROSE COMPLEX", "code_information": [ { "code": "J1756", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "RHC or FQHC only, general care management, 20 minutes or more of clinical staff time for chronic care management services", "code_information": [ { "code": "G0511", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "LIDOCAINE HCL, SYR 1%-5ML", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 10, "minimum": 10 } ] }, { "description": "COBAN 1 IN", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 7, "minimum": 7 } ] }, { "description": "THYROID PANEL -- QUEST -- 84436", "code_information": [ { "code": "84436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "THYROID PANEL -- QUEST -- 84479", "code_information": [ { "code": "84479", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "PORPHYRINS, FRACTIONATED QUANT URINE", "code_information": [ { "code": "84120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "ADALIMUMAB LEVEL FOR IBD", "code_information": [ { "code": "80145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 300, "minimum": 300 } ] }, { "description": "CRITICAL CARE, EACH ADDITIONAL 30 MINS.", "code_information": [ { "code": "99292", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 910, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 910, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 910, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 958, "minimum": 958 } ] }, { "description": "OPITISON 0.22 MG/3ML INJ", "code_information": [ { "code": "Q9956", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 46, "minimum": 46 } ] }, { "description": "GENERIC AMOXICILLIN ORAL SUSPENSION 400MG/5M", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 5.3, "minimum": 5.3 } ] }, { "description": "CANDIDA AURIS SURVEILLANCE, QUALITATIVE, REAL-TIME PCR, AX", "code_information": [ { "code": "87481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 209, "minimum": 209 } ] }, { "description": "PT SCHOOL CHARGE - 1 HR", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "PT SCHOOL CHARGE - 30 MIN", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "PT SCHOOL CHARGE - 15 MIN", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "HYALGAN 20 MG/ML INTRA-ARTICULAR SYRINGE", "drug_information": { "unit": "20", "type": "EA" }, "code_information": [ { "code": "89122072420", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Fracture and/or dislocation procedure on the forearm and wrist", "code_information": [ { "code": "25650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 750, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 703, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 806.75, "minimum": 806.75 } ] }, { "description": "MINERAL COUNTY PHYSICAL \u003e40", "code_information": [ { "code": "99396", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 480, "minimum": 480 } ] }, { "description": "MINERAL COUNTY PHYSICAL 18-39", "code_information": [ { "code": "99395", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 565, "minimum": 565 } ] }, { "description": "ARIPIPRAZOLE, QUANTITATIVE, SERUM/PLASMA -- QUEST", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "IODINE, SERUM/PLASMA -- QUEST", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 118, "minimum": 118 } ] }, { "description": "NV SPECIFIC W/C CODE OBSERVATION CARE (GREATER THAN 23 HRS)", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NV SPECIFIC W/C CODE OBSERVATION CARE (UP TO 23 HRS OR FRACTION)", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NV SPECIFIC W/C CODE MEDICAL-SURGICAL CARE", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FOSFOMYCIN TROMETHAMINE 3GM", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 295, "minimum": 295 } ] }, { "description": "FACTOR V (LEIDEN) MUTATION ANALYSIS WITH REFLEX TO HR2 MUTATION ANALYSIS", "code_information": [ { "code": "81241", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 294, "minimum": 294 } ] }, { "description": "MIN CO CHEST XR, 2 VIEW", "code_information": [ { "code": "77299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "REPAIR BLOOD VESSEL DIRECT HAND FINGER", "code_information": [ { "code": "35207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2166, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2028, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 815, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 815, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 815, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 815, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 815, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2328.87, "minimum": 2328.87 } ] }, { "description": "PRO FEE REPAIR BLOOD VESSEL DIRECT HAND FINGER", "code_information": [ { "code": "35207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1761, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1761, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1761, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1724, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1853.65, "minimum": 1853.65 } ] }, { "description": "LOWER SPINE SUPPORT BRACE - VISTA 464 TLSO", "code_information": [ { "code": "L0454", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 591, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 591, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 591, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 542, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 622, "minimum": 622 } ] }, { "description": "CENTRAL VENOUS CATHETER KIT 7FR X 16CM", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 186, "minimum": 186 } ] }, { "description": "ARIPIPRAZOLE, QUANTITATIVE, SERUM/PLASMA", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "CK-MB (CK-2)", "code_information": [ { "code": "82553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 155, "minimum": 155 } ] }, { "description": "MENACTRA (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "49281058905", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AMMONIA, PLASMA - MGGH LAB", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 129, "minimum": 129 } ] }, { "description": "HH GRANT HOMEMAKER 0.25 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6.25, "minimum": 6.25 } ] }, { "description": "HH GRANT HOMEMAKER 0.5 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12.5, "minimum": 12.5 } ] }, { "description": "OTHER PROCEDURES ON THE DENTOALVEOLAR STRUCTURES", "code_information": [ { "code": "41899", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 581, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 581, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 581, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 569, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 612, "minimum": 612 } ] }, { "description": "PRO-FEE OTHER PROCEDURES ON THE DENTOALVEOLAR STRUCTURES", "code_information": [ { "code": "41899", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 429, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 402, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 461, "minimum": 461 } ] }, { "description": "HH GRANT HOMEMAKER 1 HOUR\t", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "HH PCA-PA ATTENDANT 0.25 HOURS", "code_information": [ { "code": "T1019", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6.25, "minimum": 6.25 } ] }, { "description": "HH PCA-PA ATTENDANT 0.5 HOURS\t", "code_information": [ { "code": "T1019", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12.5, "minimum": 12.5 } ] }, { "description": "HH PCA-PA ATTENDANT 1 HOUR", "code_information": [ { "code": "T1019", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "ANABOLIC STEROIDS, SCREEN AND CONFIRMATION, URINE -- LABCORP", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 316, "minimum": 316 } ] }, { "description": "INJECTION, METRONIDAZOLE, 500 MG", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00409781124", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "63739022810", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Hydroxocobalamin 5GM Vial SUV", "code_information": [ { "code": "0636", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1372, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1372, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1372, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1343, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1258, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 506, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1444.5, "minimum": 1444.5 } ] }, { "description": "GRANUFOAM DRESSSING\t", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 13, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 14.61, "minimum": 14.61 } ] }, { "description": "SWING BED", "code_information": [ { "code": "0129", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1581, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1481, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1700, "minimum": 1700 } ] }, { "description": "TELEMETRY ROOM (PRIVATE)", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1975, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2267, "minimum": 2267 } ] }, { "description": "TELEHEALTH ORIGINATING SITE FEE", "code_information": [ { "code": "Q3014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 93, "minimum": 93 } ] }, { "description": "OBSERVATION ROOM TRANSFER", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "OBSERVATION ISOLATION/TELEMETRY ROOM TRANSFER", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "MNT; INIT ASSESSMENT \u0026 INTERVENTION, INDIVIDUAL, FACE-TO-FACE W/ PATIENT, EACH 15 MIN", "code_information": [ { "code": "97802", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "MNT; REASSESSMENT \u0026 INTERVENTION, INDIVIDUAL, FACE-TO-FACE W/ PATIENT, EACH 15 MIN", "code_information": [ { "code": "97803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 83, "minimum": 83 } ] }, { "description": "SUTURE REMOVAL", "code_information": [ { "code": "99211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "HYDRATION 31-60 MIN", "code_information": [ { "code": "96360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 478, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 514, "minimum": 514 } ] }, { "description": "DRESSING CHANGE COMPLEX", "code_information": [ { "code": "99211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "BLADDER CATH TEMP INDWELL", "code_information": [ { "code": "51702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 278, "minimum": 278 } ] }, { "description": "IV PUSH INITIAL", "code_information": [ { "code": "96374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 311, "minimum": 311 } ] }, { "description": "THER. EA ADD HR\u003e30MIN", "code_information": [ { "code": "96366", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "PHARMACY INJ FEE", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "PHLEBOTOMY THERAPEUTIC", "code_information": [ { "code": "99195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 250, "minimum": 250 } ] }, { "description": "THERAPEUTIC 16-60 MIN", "code_information": [ { "code": "96365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 576, "minimum": 576 } ] }, { "description": "IV PUSH NEW SUBSTANCE", "code_information": [ { "code": "96375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "IV PUSH SAME SUBSTANCE", "code_information": [ { "code": "96376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "HYDRA EA AD HR\u003e30 MIN", "code_information": [ { "code": "96361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "HYDRATION 31-60 MIN", "code_information": [ { "code": "96360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 478, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 514, "minimum": 514 } ] }, { "description": "IV PUSH INITIAL", "code_information": [ { "code": "96374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 311, "minimum": 311 } ] }, { "description": "APPLY SPLINT, SHORT ARM", "code_information": [ { "code": "29125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 355, "minimum": 355 } ] }, { "description": "APPLY SHORT LEG SPLINT", "code_information": [ { "code": "29515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "EMERGENCY DEPARTMENT VISIT LIMITED/MINOR PROB", "code_information": [ { "code": "99281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 318, "minimum": 318 } ] }, { "description": "EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY", "code_information": [ { "code": "99284", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1567, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1567, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1567, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1534, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1436, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1649, "minimum": 1649 } ] }, { "description": "REPAIR COMP. 2.6CM-7.5CM", "code_information": [ { "code": "13121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1448, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1448, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1448, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1417, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1524, "minimum": 1524 } ] }, { "description": "EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY", "code_information": [ { "code": "99282", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 561, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 561, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 561, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 515, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 591, "minimum": 591 } ] }, { "description": "EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY", "code_information": [ { "code": "99283", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1003, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 939, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1078, "minimum": 1078 } ] }, { "description": "CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN", "code_information": [ { "code": "99291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3116, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2919, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3351, "minimum": 3351 } ] }, { "description": "Administrative Room Day", "code_information": [ { "code": "0160", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1710, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1710, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1710, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1674, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1568, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 630, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1800, "minimum": 1800 } ] }, { "description": "MED/SURG ROOM (SEMI-PRIVATE)", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1770, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1658, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1903, "minimum": 1903 } ] }, { "description": "PELVIS NON OB ULTRA SOUND LIMITED", "code_information": [ { "code": "76857", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 682, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 682, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 682, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 668, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 625, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 718, "minimum": 718 } ] }, { "description": "OB U/S 1ST TRIMESTER", "code_information": [ { "code": "76801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 775, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 711, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 816, "minimum": 816 } ] }, { "description": "CHEST ULTRASOUND ST NON BREAST", "code_information": [ { "code": "76604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 806, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 806, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 806, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 739, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 848, "minimum": 848 } ] }, { "description": "RENAL DOPPLER US - COMPLETE", "code_information": [ { "code": "93975", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1341, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1256, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1442, "minimum": 1442 } ] }, { "description": "DOPPLER SCAN XCRANIAL BILAT (CAROTID)", "code_information": [ { "code": "93880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1447, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1416, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 533, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1523, "minimum": 1523 } ] }, { "description": "BILAT DOPPLER LOW EXT ARTERY", "code_information": [ { "code": "93925", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1421, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1421, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1421, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1391, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1303, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 524, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 524, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 524, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 524, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 524, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1496, "minimum": 1496 } ] }, { "description": "ABDOMINAL AORTA ULTRASOUND", "code_information": [ { "code": "76770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 716, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 671, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 770, "minimum": 770 } ] }, { "description": "TRANSVAGINAL ULTRA SOUND", "code_information": [ { "code": "76830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 750, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 702, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 806, "minimum": 806 } ] }, { "description": "CMPL BILAT VENOUS STUD US", "code_information": [ { "code": "93970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1288, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1261, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1181, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1356, "minimum": 1356 } ] }, { "description": "LIMITED VENOUS STUDIES US", "code_information": [ { "code": "93971", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 802, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 802, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 802, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 785, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 735, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 844, "minimum": 844 } ] }, { "description": "S T NECK", "code_information": [ { "code": "76536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 770, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 754, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 811, "minimum": 811 } ] }, { "description": "COMPLETE ABDOMEN U S", "code_information": [ { "code": "76700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 949, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 949, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 949, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 929, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 870, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 999, "minimum": 999 } ] }, { "description": "LIMITED ABDOMEN U S", "code_information": [ { "code": "76705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 782, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 782, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 782, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 765, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 823, "minimum": 823 } ] }, { "description": "RENAL ULTRA SOUND", "code_information": [ { "code": "76770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 716, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 671, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 770, "minimum": 770 } ] }, { "description": "OB U/S GESTATION", "code_information": [ { "code": "76805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 962, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 962, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 962, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 942, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 882, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 355, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1013, "minimum": 1013 } ] }, { "description": "ECHOCARDIOGRAM, LIMITED", "code_information": [ { "code": "93308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1107, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1083, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1015, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1165, "minimum": 1165 } ] }, { "description": "OB ULTRA SOUND LIMITED", "code_information": [ { "code": "76815", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 652, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 611, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 701, "minimum": 701 } ] }, { "description": "BREAST RT ULTRA SOUND", "code_information": [ { "code": "76641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 582, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 626, "minimum": 626 } ] }, { "description": "SPCH/LANG EVAL SWALL/FEED", "code_information": [ { "code": "92610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 394, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 424, "minimum": 424 } ] }, { "description": "SPEECH TREATMENT-15 MIN", "code_information": [ { "code": "92507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 270, "minimum": 270 } ] }, { "description": "SPEECH/LANG EVAL", "code_information": [ { "code": "92523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 526, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 493, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 566, "minimum": 566 } ] }, { "description": "ASSESSMENT OF APHASIA", "code_information": [ { "code": "96105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 480, "minimum": 480 } ] }, { "description": "CHEST PERCUSSION INITIAL", "code_information": [ { "code": "94667", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "INTUBATION - IP", "code_information": [ { "code": "31500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 831, "minimum": 831 } ] }, { "description": "CARDIOVASC STRESS TEST", "code_information": [ { "code": "93015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 599, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 599, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 599, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 587, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 631, "minimum": 631 } ] }, { "description": "CONT NEBUL THER-1ST HR", "code_information": [ { "code": "94644", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 354, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 354, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 354, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 373, "minimum": 373 } ] }, { "description": "VENTILATOR PER DAY UNIT", "code_information": [ { "code": "94002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2731, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2731, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2731, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2674, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2504, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1006, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1006, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1006, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1006, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1006, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2875, "minimum": 2875 } ] }, { "description": "ARTERIAL PUNCTURE", "code_information": [ { "code": "36600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 240, "minimum": 240 } ] }, { "description": "CPAP, INIT\u0026MGMT", "code_information": [ { "code": "94660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 872, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 872, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 872, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 854, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 800, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 918, "minimum": 918 } ] }, { "description": "FLUTTER VALVE INITIAL", "code_information": [ { "code": "94667", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "INTUBATION - OP", "code_information": [ { "code": "31500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 789, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 831, "minimum": 831 } ] }, { "description": "PFT COMPLETE", "code_information": [ { "code": "94060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 645, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 645, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 645, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 631, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 591, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 679, "minimum": 679 } ] }, { "description": "XR--FEMUR.LEFT--VIEWS", "code_information": [ { "code": "73552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 400, "minimum": 400 } ] }, { "description": "XR--TOE.SECOND.RIGHT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 356, "minimum": 356 } ] }, { "description": "XR--SPINE.CERVICAL--COMPLETE, INCL OBLIQUE FLEXION EXT STUDIES", "code_information": [ { "code": "72052", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 705, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 705, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 705, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 690, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 742, "minimum": 742 } ] }, { "description": "XR--FACIAL BONES--VIEWS 3", "code_information": [ { "code": "70150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 594, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 594, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 594, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 581, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 544, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 625, "minimum": 625 } ] }, { "description": "XR--TOE.SECOND.LEFT--VIEWS", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 356, "minimum": 356 } ] }, { "description": "XR--WRIST.BILATERAL+HAND.BILATERAL--VIEWS BONE AGE", "code_information": [ { "code": "77072", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 493, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 530, "minimum": 530 } ] }, { "description": "XR--CALCANEUS.LEFT--VIEWS", "code_information": [ { "code": "73650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 365, "minimum": 365 } ] }, { "description": "XR--MANDIBLE--VIEWS 4", "code_information": [ { "code": "70110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 469, "minimum": 469 } ] }, { "description": "XR--SHOULDER.RIGHT--VIEW 1", "code_information": [ { "code": "73020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 297, "minimum": 297 } ] }, { "description": "XR--FINGER.SECOND.LEFT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 325, "minimum": 325 } ] }, { "description": "XR--LOWER EXTREMITY.LEFT--VIEWS", "code_information": [ { "code": "73592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 332, "minimum": 332 } ] }, { "description": "XR--THUMB.LEFT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 325, "minimum": 325 } ] }, { "description": "XR--NECK--VIEWS AP \u0026 LATERAL", "code_information": [ { "code": "70360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 325, "minimum": 325 } ] }, { "description": "XR—CHEST—VIEWS AP", "code_information": [ { "code": "71045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 341, "minimum": 341 } ] }, { "description": "TM JOINTS BILATERAL", "code_information": [ { "code": "70330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 490, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 562, "minimum": 562 } ] }, { "description": "XR--STERNUM--VIEWS", "code_information": [ { "code": "71120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 378, "minimum": 378 } ] }, { "description": "XR--SPINE.THORACIC+SPINE.LUMBAR--VIEWS 2 SCOLIOSIS", "code_information": [ { "code": "72082", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 516, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 516, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 516, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 505, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 543, "minimum": 543 } ] }, { "description": "XR--FINGER.SECOND.RIGHT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 325, "minimum": 325 } ] }, { "description": "XR--KNEE.LEFT--VIEWS 2", "code_information": [ { "code": "73560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 358, "minimum": 358 } ] }, { "description": "XR--KNEE.RIGHT--VIEWS 2", "code_information": [ { "code": "73560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 358, "minimum": 358 } ] }, { "description": "XR--CALCANEUS.RIGHT--VIEWS", "code_information": [ { "code": "73650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 347, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 318, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 365, "minimum": 365 } ] }, { "description": "XR--SPINE.THORACOLUMBAR JUNCTION--VIEWS 2", "code_information": [ { "code": "72080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 396, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 455, "minimum": 455 } ] }, { "description": "XR--SPINE.LUMBAR--VIEWS 5^W FLEXION \u0026 W EXTENSION", "code_information": [ { "code": "72114", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 759, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 743, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 696, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 799, "minimum": 799 } ] }, { "description": "XR--SINUSES--VIEWS 3", "code_information": [ { "code": "70220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 530, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 530, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 530, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 519, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 486, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 558, "minimum": 558 } ] }, { "description": "XR--SPINE.CERVICAL--VIEWS 2 OR 3", "code_information": [ { "code": "72040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 397, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 397, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 397, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 389, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 364, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 418, "minimum": 418 } ] }, { "description": "XR--RIBS.LEFT--VIEWS 3", "code_information": [ { "code": "71101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 454, "minimum": 454 } ] }, { "description": "XR--HUMERUS.LEFT--VIEWS", "code_information": [ { "code": "73060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 378, "minimum": 378 } ] }, { "description": "XR--HUMERUS.RIGHT--VIEWS", "code_information": [ { "code": "73060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 378, "minimum": 378 } ] }, { "description": "XR--ELBOW.LEFT--VIEWS", "code_information": [ { "code": "73070,LT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 354, "minimum": 354 } ] }, { "description": "XR--RIBS.RIGHT--VIEWS 3", "code_information": [ { "code": "71101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 431, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 454, "minimum": 454 } ] }, { "description": "XR--ABDOMEN--VIEWS 2", "code_information": [ { "code": "74021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 654, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 751, "minimum": 751 } ] }, { "description": "XR--SPINE.THORACIC--VIEWS 3", "code_information": [ { "code": "72072", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 486, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 486, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 486, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 476, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 512, "minimum": 512 } ] }, { "description": "XR--ABDOMEN--VIEWS 3", "code_information": [ { "code": "74022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 592, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 637, "minimum": 637 } ] }, { "description": "XR--WRIST.RIGHT--VIEWS 3", "code_information": [ { "code": "73110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 349, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 401, "minimum": 401 } ] }, { "description": "XR--WRIST.LEFT--VIEWS 3", "code_information": [ { "code": "73110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 381, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 349, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 401, "minimum": 401 } ] }, { "description": "XR--KNEE.LEFT--VIEWS 4", "code_information": [ { "code": "73564,LT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 484, "minimum": 484 } ] }, { "description": "XR--ELBOW.RIGHT--VIEWS", "code_information": [ { "code": "73070,RT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 354, "minimum": 354 } ] }, { "description": "XR--SPINE.CERVICAL--VIEWS 4 or 5", "code_information": [ { "code": "72050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 574, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 574, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 574, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 562, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 526, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 604, "minimum": 604 } ] }, { "description": "XR--KNEE.RIGHT--VIEWS 4", "code_information": [ { "code": "73564,RT", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 484, "minimum": 484 } ] }, { "description": "XR--PELVIS+HIP.BILATERAL--VIEWS", "code_information": [ { "code": "73521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 713, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 698, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 654, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 263, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 751, "minimum": 751 } ] }, { "description": "XR--ANKLE.LEFT--VIEWS 3", "code_information": [ { "code": "73610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 387, "minimum": 387 } ] }, { "description": "XR--FOOT.RIGHT--VIEWS 3 OR 4", "code_information": [ { "code": "73630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 388, "minimum": 388 } ] }, { "description": "XR--HIP.LEFT--VIEWS 2", "code_information": [ { "code": "73502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 413, "minimum": 413 } ] }, { "description": "XR--KNEE.RIGHT--VIEWS 3", "code_information": [ { "code": "73562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "XR--ANKLE.RIGHT--VIEWS 3", "code_information": [ { "code": "73610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 368, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 337, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 387, "minimum": 387 } ] }, { "description": "XR--HIP.RIGHT--VIEWS 2", "code_information": [ { "code": "73502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 360, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 413, "minimum": 413 } ] }, { "description": "XR--HAND.RIGHT--VIEWS 3", "code_information": [ { "code": "73130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "XR--HAND.LEFT--VIEWS 3", "code_information": [ { "code": "73130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "XR--KNEE.LEFT--VIEWS 3", "code_information": [ { "code": "73562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "XR--FOOT.LEFT--VIEWS 3 OR 4", "code_information": [ { "code": "73630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 388, "minimum": 388 } ] }, { "description": "XR--ABDOMEN--VIEW 1", "code_information": [ { "code": "74018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 346, "minimum": 346 } ] }, { "description": "XR--SHOULDER.LEFT--VIEWS 3", "code_information": [ { "code": "73030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 412, "minimum": 412 } ] }, { "description": "XR--SHOULDER.RIGHT--VIEWS 3", "code_information": [ { "code": "73030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 391, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 412, "minimum": 412 } ] }, { "description": "XR--CHEST--VIEWS PA \u0026 LATERAL UPRIGHT", "code_information": [ { "code": "71046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 389, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 389, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 389, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 409, "minimum": 409 } ] }, { "description": "XR--CHEST--VIEWS AP PORTABLE", "code_information": [ { "code": "71045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 341, "minimum": 341 } ] }, { "description": "XR--SACROILIAC JOINT--VIEWS", "code_information": [ { "code": "72202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 482, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 451, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 518, "minimum": 518 } ] }, { "description": "XR--THUMB.RIGHT--VIEWS", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 309, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 283, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 325, "minimum": 325 } ] }, { "description": "XR--SHOULDER.LEFT--VIEW 1", "code_information": [ { "code": "73020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 282, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 297, "minimum": 297 } ] }, { "description": "XR--SKULL--VIEWS 3", "code_information": [ { "code": "70250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 469, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 469, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 469, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 459, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 494, "minimum": 494 } ] }, { "description": "XR--NASAL BONES--VIEWS", "code_information": [ { "code": "70160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 406, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 406, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 406, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 397, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 427, "minimum": 427 } ] }, { "description": "XR--SCAPULA.LEFT--VIEWS", "code_information": [ { "code": "73010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 356, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 349, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 375, "minimum": 375 } ] }, { "description": "P/T RE-EVAL EST PLAN CARE", "code_information": [ { "code": "97164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 164, "minimum": 164 } ] }, { "description": "TRACTION MECHANICAL", "code_information": [ { "code": "97012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "P/T EVAL LOW COMPLEX 20 MINS (FM)", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 256, "minimum": 256 } ] }, { "description": "MANIPULATION MANUAL THER", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "THERAPEUTIC MASSAGE", "code_information": [ { "code": "97124", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "ULTRASOUND EA 15 MINS", "code_information": [ { "code": "97035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 96, "minimum": 96 } ] }, { "description": "Selfcare Training - Home Management", "code_information": [ { "code": "97535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 140, "minimum": 140 } ] }, { "description": "P/T EVAL LOW COMPLEX 20 MINS", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 256, "minimum": 256 } ] }, { "description": "NEUROMUSCULAR RE-ED", "code_information": [ { "code": "97112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "GAIT TRAINING", "code_information": [ { "code": "97116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "FUNCTIONAL ACT TRAIN", "code_information": [ { "code": "97530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "ELECTRICAL STIMULATION", "code_information": [ { "code": "97014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "MANUAL THERAPY", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "THERAPEUTIC EXERCISE (FM)", "code_information": [ { "code": "97110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "THERAPEUTIC EXERCISE", "code_information": [ { "code": "97110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 137, "minimum": 137 } ] }, { "description": "Application of a modality to 1 or more areas; hot or cold packs", "code_information": [ { "code": "97010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "ELECTRICAL STIM (MANUAL)", "code_information": [ { "code": "97032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "PHYS PERF TEST WITH RPT", "code_information": [ { "code": "97750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 140, "minimum": 140 } ] }, { "description": "WHEELCHR/PROPULSION TRAIN", "code_information": [ { "code": "97542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "IONTOPHORESIS 1 UNIT", "code_information": [ { "code": "97033", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 126, "minimum": 126 } ] }, { "description": "PROGESTERONE", "code_information": [ { "code": "84144", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 205, "minimum": 205 } ] }, { "description": "TISSUE TRANSGLUTAMINASE (TTG) ANTIBODIES (IGG, IGA)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "SEX HORMONE BINDING GLOBULIN (SHBG)", "code_information": [ { "code": "84270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 207, "minimum": 207 } ] }, { "description": "FECAL FAT, QUALITATIVE", "code_information": [ { "code": "82705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "SEROTONIN, SERUM", "code_information": [ { "code": "84260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 292, "minimum": 292 } ] }, { "description": "METANEPHRINES, FRACTIONATED, LC/MS/MS, 24-HOUR URINE", "code_information": [ { "code": "83835", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 201, "minimum": 201 } ] }, { "description": "H. PYLORI AG DET, EIA, STOOL", "code_information": [ { "code": "87338", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 179, "minimum": 179 } ] }, { "description": "JO-1 ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODY", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "CATECHOLAMINES, FRACTIONATED, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "82384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 272, "minimum": 272 } ] }, { "description": "ALPHA-1-ANTITRYPSIN", "code_information": [ { "code": "82103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 156, "minimum": 156 } ] }, { "description": "MEASLES ANTIBODY (IGG)", "code_information": [ { "code": "86765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 116, "minimum": 116 } ] }, { "description": "SMOOTH MUSCLE ANTIBODY WITH REFLEX TO TITER", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "PHENOBARBITAL", "code_information": [ { "code": "80184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "COLD HEMAGGLUTININS", "code_information": [ { "code": "86157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 129, "minimum": 129 } ] }, { "description": "CHLORIDE, RANDOM URINE WITHOUT CREATININE", "code_information": [ { "code": "82436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "ELECTROLYTES, RANDOM URINE 1", "code_information": [ { "code": "82436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "THEOPHYLLINE", "code_information": [ { "code": "80198", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 160, "minimum": 160 } ] }, { "description": "CULTURE, ANAEROBIC BACTERIA WITH GRAM STAIN", "code_information": [ { "code": "87075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 143, "minimum": 143 } ] }, { "description": "HEMOGLOBIN A1C WITH CALCULATED MEAN PLASMA GLUCOSE (MPG)", "code_information": [ { "code": "83036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 104, "minimum": 104 } ] }, { "description": "TREPONEMA PALLIDUM AB, PARTICLE AGGLUTINATION -- QUEST", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 119, "minimum": 119 } ] }, { "description": "CHROMATIN (NUCLEOSOMAL) ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "CHROMOGRANIN A, ELECTROCHEMILUMINESCENCE", "code_information": [ { "code": "86316", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 193, "minimum": 193 } ] }, { "description": "CENTROMERE B ANTIBODY", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 121, "minimum": 121 } ] }, { "description": "HAPTOGLOBIN", "code_information": [ { "code": "83010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "ALKALINE PHOSPHATASE ISOENZYMES -- LABCORP (84080)", "code_information": [ { "code": "84080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 130, "minimum": 130 } ] }, { "description": "POSTASSIUM, RANDOM URINE WITHOUT CREATININE", "code_information": [ { "code": "84133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 66, "minimum": 66 } ] }, { "description": "ELECTROLYTES, RANDOM URINE 2", "code_information": [ { "code": "84133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 66, "minimum": 66 } ] }, { "description": "ELECTROLYTES, RANDOM URINE 3", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 52, "minimum": 52 } ] }, { "description": "THYROID CASCADE PROFILE", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 167, "minimum": 167 } ] }, { "description": "ELECTROLYTES, RANDOM URINE 4", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "HEPATITIS B CORE ANTIBODY (IGM)", "code_information": [ { "code": "86705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 119, "minimum": 119 } ] }, { "description": "ESTROGEN, TOTAL", "code_information": [ { "code": "82672", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 185, "minimum": 185 } ] }, { "description": "HEPATITIS A ANTIBODY, TOTAL", "code_information": [ { "code": "86708", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "TSH, 3 RD GENERATION", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 167, "minimum": 167 } ] }, { "description": "CHROMOGRANIN A, LC/MS/MS -- QUEST", "code_information": [ { "code": "86316", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 193, "minimum": 193 } ] }, { "description": "Immunofixation electrophoresis; serum", "code_information": [ { "code": "86334", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 164, "minimum": 164 } ] }, { "description": "Fractionated bilirubin", "code_information": [ { "code": "82247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "THIOPURINE S-METHYLTRANSFERASE(TPMT) GENOTYPE -- QUEST", "code_information": [ { "code": "81335", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 664, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 664, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 664, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 650, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 609, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 699, "minimum": 699 } ] }, { "description": "CADMIUM, BLOOD", "code_information": [ { "code": "82300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 222, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 255, "minimum": 255 } ] }, { "description": "GROWTH HORMONE (GH)", "code_information": [ { "code": "83003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 148, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 159, "minimum": 159 } ] }, { "description": "SCLERODERMA ANTIBODIES (SCL-70)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 10", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "VITAMIN B12 (COBALAMIN) AND FOLATE PANEL, SERUM", "code_information": [ { "code": "82607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 190, "minimum": 190 } ] }, { "description": "CULTURE, THROAT", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "THYROGLOBULIN ANTIBODIES", "code_information": [ { "code": "86800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "CORTISOL, TOTAL", "code_information": [ { "code": "82533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 177, "minimum": 177 } ] }, { "description": "ANA IFA TITER; ANA PATTERN", "code_information": [ { "code": "86039", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "SODIUM, RANDOM URINE WITHOUT CREATININE", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 52, "minimum": 52 } ] }, { "description": "CA 125", "code_information": [ { "code": "86304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "EKG WITH RHYTHM STRIP", "code_information": [ { "code": "93005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 310, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 290, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 333, "minimum": 333 } ] }, { "description": "ACETAMINIOPHEN", "code_information": [ { "code": "80329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 196, "minimum": 196 } ] }, { "description": "CK (CPK) TOTAL", "code_information": [ { "code": "82550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "OCCULT BLOOD (ONCE)", "code_information": [ { "code": "82274", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "D-DIMER", "code_information": [ { "code": "85362", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "PTT", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 118, "minimum": 118 } ] }, { "description": "SALICYLATES", "code_information": [ { "code": "80329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 196, "minimum": 196 } ] }, { "description": "URINALYSIS W/O MICRO", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 15, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 42, "minimum": 42 } ] }, { "description": "DNA (DS) ANTIBODIES", "code_information": [ { "code": "86225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "IRON, TOTAL", "code_information": [ { "code": "83540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "SJOGREN\u0027S ANTIBODIES (SS-B)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "SJOGREN\u0027S ANTIBODIES (SS-A)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "URINE CREATININE", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "SM/RNP ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "VENOUS BLOOD GAS (EPOC) -- MGGH LAB", "code_information": [ { "code": "82805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 388, "minimum": 388 } ] }, { "description": "HISTONE ANTIBODIES", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "IMMUNOFIXATION (IFE), SERUM", "code_information": [ { "code": "86334", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 164, "minimum": 164 } ] }, { "description": "URINE PROTEIN", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "LAYER CLOSURE 2.6-7.5 CM", "code_information": [ { "code": "12042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 848, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 794, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 912, "minimum": 912 } ] }, { "description": "LAYER CLOSURE \u003c2.5CM", "code_information": [ { "code": "12041", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 826, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 888, "minimum": 888 } ] }, { "description": "CLSD TXT RADIAL/ULNR FRAC", "code_information": [ { "code": "25560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 887, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 869, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 814, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 934, "minimum": 934 } ] }, { "description": "I\u0026D ABCESS,COMP OR MUL", "code_information": [ { "code": "10061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 592, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 637, "minimum": 637 } ] }, { "description": "SPLINT THIGH TO TOES", "code_information": [ { "code": "29505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 419, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 441, "minimum": 441 } ] }, { "description": "LAYER CLOSURE \u003c2.5CM", "code_information": [ { "code": "12051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 891, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 872, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 817, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 938, "minimum": 938 } ] }, { "description": "CONTROL NASAL HEMMOR.COM", "code_information": [ { "code": "30903", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 181, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 517, "minimum": 517 } ] }, { "description": "DRAINAGE OF ABSCESS, CYST, HEATOMA FROM DENTOALVEOLAR STRUCTURES", "code_information": [ { "code": "41800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 658, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 755, "minimum": 755 } ] }, { "description": "HEPATITIS C VIRAL RNA, GENOTYPE", "code_information": [ { "code": "87902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1147, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1123, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1207, "minimum": 1207 } ] }, { "description": "LE RT NON JNT WO/W CONTR", "code_information": [ { "code": "73720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3441, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3441, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3441, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3368, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3155, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3622, "minimum": 3622 } ] }, { "description": "LE RT NON JNT WO CONTRAST", "code_information": [ { "code": "73718", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2376, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2225, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2555, "minimum": 2555 } ] }, { "description": "PELVIS WO CONTRAST MRI", "code_information": [ { "code": "72195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2385, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2335, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 879, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2511, "minimum": 2511 } ] }, { "description": "MRA ABDOMEN", "code_information": [ { "code": "74185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2279, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2135, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 858, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2451, "minimum": 2451 } ] }, { "description": "UE LT NON JNT WO CONTR", "code_information": [ { "code": "73218", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2480, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2667, "minimum": 2667 } ] }, { "description": "LE LT NON JNT WO CONTR", "code_information": [ { "code": "73718", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2427, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2376, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2225, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2555, "minimum": 2555 } ] }, { "description": "T SPINE WO CONTRAST MRI", "code_information": [ { "code": "72146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2697, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2697, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2697, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2640, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2473, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 994, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 994, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 994, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 994, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 994, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2839, "minimum": 2839 } ] }, { "description": "C SPINE WO CONTRAST MRI", "code_information": [ { "code": "72141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2482, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2482, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2482, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2430, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2276, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2613, "minimum": 2613 } ] }, { "description": "L SPINE WO CONTRAST MRI", "code_information": [ { "code": "72148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2573, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2573, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2573, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2518, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2359, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 948, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 948, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 948, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 948, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 948, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2708, "minimum": 2708 } ] }, { "description": "PELVIS WO/W CONTR MRI", "code_information": [ { "code": "72197", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3020, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3020, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3020, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2956, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2769, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3179, "minimum": 3179 } ] }, { "description": "LE LT NON JNT WO/W CONTR", "code_information": [ { "code": "73720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3441, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3441, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3441, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3368, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 3155, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1268, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3622, "minimum": 3622 } ] }, { "description": "TEMPOROMANDIBULAR JOINTS", "code_information": [ { "code": "70336", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3151, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2951, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3388, "minimum": 3388 } ] }, { "description": "UE RT NON JNT WO/W CONTR", "code_information": [ { "code": "73220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3046, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2853, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1146, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3275, "minimum": 3275 } ] }, { "description": "UE RT NON JNT WO CONTRAST", "code_information": [ { "code": "73218", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2534, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2480, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 933, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2667, "minimum": 2667 } ] }, { "description": "L SPINE W CONTRAST MRI", "code_information": [ { "code": "72149", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2780, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2780, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2780, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2721, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2549, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1024, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2926, "minimum": 2926 } ] }, { "description": "FACTOR V (LEIDEN) MUTATION ANALYSIS", "code_information": [ { "code": "81241", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 460, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 528, "minimum": 528 } ] }, { "description": "ACUTE HEPATITIS PANEL (REFL)", "code_information": [ { "code": "80074", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 438, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 429, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 402, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 461, "minimum": 461 } ] }, { "description": "AMMONIA, PLASMA", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 190, "minimum": 190 } ] }, { "description": "Insulin, Free", "code_information": [ { "code": "83527", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 182, "minimum": 182 } ] }, { "description": "PLA2R ANTIBODY PANEL -- QUEST -- CPT 83520", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "PLA2R ANTIBODY PANEL -- QUEST -- CPT 86255", "code_information": [ { "code": "86255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "HOMOCYSTEINE, CARDIOVASCULAR", "code_information": [ { "code": "83090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 232, "minimum": 232 } ] }, { "description": "VARICELLA-ZOSTER VIRUS ANTIBODY (IGG)", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 148, "minimum": 148 } ] }, { "description": "ERYTHROPOIETIN", "code_information": [ { "code": "82668", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 238, "minimum": 238 } ] }, { "description": "NASH FIBROSURE -- LABCORP (82977)", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "NASH FIBROSURE -- LABCORP (83010)", "code_information": [ { "code": "83010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "NASH FIBROSURE -- LABCORP (82172)", "code_information": [ { "code": "82172", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "NASH FIBROSURE -- LABCORP (83883)", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "MICROALBUMIN, RANDOM URINE WITHOUT CREATININE", "code_information": [ { "code": "82043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 79, "minimum": 79 } ] }, { "description": "NASH FIBROSURE -- LABCORP (84450)", "code_information": [ { "code": "84450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "NASH FIBROSURE -- LABCORP (84460)", "code_information": [ { "code": "84460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "NASH FIBROSURE -- LABCORP (82247)", "code_information": [ { "code": "82247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "PROTEIN, TOTAL, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "NASH FIBROSURE -- LABCORP (82947)", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "EPSTEIN-BARR VIRUS ANTIBODY PANEL 1", "code_information": [ { "code": "86664", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 148, "minimum": 148 } ] }, { "description": "ACETYLCHOLINE RECEPTOR BINDING ANTIBODY", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "EPSTEIN-BARR VIRUS ANTIBODY PANEL 2", "code_information": [ { "code": "86665", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "EPSTEIN-BARR VIRUS ANTIBODY PANEL 3", "code_information": [ { "code": "86665", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "FTA-ABS", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 119, "minimum": 119 } ] }, { "description": "TISSUE TRANSGLUTAMINASE (TTG) ANTIBODY (IGA)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "CERULOPLASMIN", "code_information": [ { "code": "82390", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "NASH FIBROSURE -- LABCORP (82465)", "code_information": [ { "code": "82465", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 74, "minimum": 74 } ] }, { "description": "NASH FIBROSURE -- LABCORP (84478)", "code_information": [ { "code": "84478", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 70, "minimum": 70 } ] }, { "description": "GAMMA GLUTAMYL TRANSFERASE (GGT)", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 98, "minimum": 98 } ] }, { "description": "CA 19-9", "code_information": [ { "code": "86301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 213, "minimum": 213 } ] }, { "description": "LACOSAMIDE, LC/MS/MS", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 211, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 222, "minimum": 222 } ] }, { "description": "17-HYDROXYPROGESTERONE, LC/MS/MS", "code_information": [ { "code": "83498", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 252, "minimum": 252 } ] }, { "description": "VON WILLEBRAND COMPREHENSIVE PANEL -- QUEST -- CPT 85240", "code_information": [ { "code": "85240", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "VON WILLEBRAND COMPREHENSIVE PANEL -- QUEST -- CPT 85246", "code_information": [ { "code": "85246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 264, "minimum": 264 } ] }, { "description": "LEGAL BLOOD ALCOHOL NHP (WITHIN HOURS)", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 157, "minimum": 157 } ] }, { "description": "VON WILLEBRAND COMPREHENSIVE PANEL -- QUEST -- CPT 85247", "code_information": [ { "code": "85247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 279, "minimum": 279 } ] }, { "description": "VON WILLEBRAND COMPREHENSIVE PANEL -- QUEST -- CPT 85245", "code_information": [ { "code": "85245", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 265, "minimum": 265 } ] }, { "description": "VON WILLEBRAND COMPREHENSIVE PANEL -- QUEST -- CPT 85730", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 118, "minimum": 118 } ] }, { "description": "IGF-1, LC/MS", "code_information": [ { "code": "84305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 269, "minimum": 269 } ] }, { "description": "ANTIPHOSPHOLIPID ANTIBODY PANEL -- QUEST -- CPT 86147", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 231, "minimum": 231 } ] }, { "description": "PREALBUMIN", "code_information": [ { "code": "84134", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 140, "minimum": 140 } ] }, { "description": "ANTIPHOSPHOLIPID ANTIBODY PANEL -- QUEST -- CPT 86416", "code_information": [ { "code": "86146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "ANTIPHOSPHOLIPID ANTIBODY PANEL -- QUEST -- CPT 86148", "code_information": [ { "code": "86148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 161, "minimum": 161 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 11", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 12", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 13", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 14", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 15", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 16", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 17", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 18", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 19", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 20", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 21", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 22", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 1", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 2", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 3", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 6", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 7", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 8", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 9", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 4", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "RESPIRATORY ALLERGY PROFILE REGION XV: ID (SOUTH), NV 5", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 77, "minimum": 77 } ] }, { "description": "ZONISAMIDE", "code_information": [ { "code": "80203", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 171, "minimum": 171 } ] }, { "description": "CRP, QUANTITATIVE -- LABCORP", "code_information": [ { "code": "86140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 94, "minimum": 94 } ] }, { "description": "LDH LACTATE DEHYDROGENASE (LD)", "code_information": [ { "code": "83615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 74, "minimum": 74 } ] }, { "description": "LEVETIRACETAM", "code_information": [ { "code": "80177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 150, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 158, "minimum": 158 } ] }, { "description": "TESTOSTERONE, FREE", "code_information": [ { "code": "84402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 220, "minimum": 220 } ] }, { "description": "HEPATITIS B SURFACE ANTIBODY, QUANTITATIVE", "code_information": [ { "code": "86317", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "INSULIN, FASTING", "code_information": [ { "code": "83525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 121, "minimum": 121 } ] }, { "description": "HETEROPHILE, MONO SCREEN -- QUEST -- CPT 86308", "code_information": [ { "code": "86308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 94, "minimum": 94 } ] }, { "description": "PROTEIN ELECTROPHORESIS, RANDOM URINE (UPEP) 1 (TOTAL PROTEIN)", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "PROTEIN ELECTROPHORESIS, RANDOM URINE (UPEP) 2 (PROTEIN ELECTROPHORESIS)", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "ZINC, SERUM", "code_information": [ { "code": "84630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 105, "minimum": 105 } ] }, { "description": "COMPLEMENT COMPONENT C3C", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 136, "minimum": 136 } ] }, { "description": "PROTEIN ELECTROPHORESIS (SPEP)", "code_information": [ { "code": "84165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "TOTAL PROTEIN (SPEP)", "code_information": [ { "code": "84155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 56, "minimum": 56 } ] }, { "description": "RPR (DIAGNOSIS) WITH REFLEX TO TITER AND CONFIRMATORY TESTING", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 119, "minimum": 119 } ] }, { "description": "THYROGLOBULIN", "code_information": [ { "code": "84432", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 186, "minimum": 186 } ] }, { "description": "T4 (THYROXINE), TOTAL", "code_information": [ { "code": "84436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 108, "minimum": 108 } ] }, { "description": "RETICULOCYTE COUNT, AUTOMATED", "code_information": [ { "code": "85045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 50, "minimum": 50 } ] }, { "description": "CORTISOL, A.M.", "code_information": [ { "code": "82533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 177, "minimum": 177 } ] }, { "description": "ALPHA-FETOPROTEIN, TUMOR MARKER", "code_information": [ { "code": "82105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 147, "minimum": 147 } ] }, { "description": "QUESTASSURED 25-HYDROXYVITAMIN D (D 2, D 3), LC/MS/MS", "code_information": [ { "code": "82306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 318, "minimum": 318 } ] }, { "description": "LEGAL BLOOD ALCOHOL (WITHIN HOURS)", "code_information": [ { "code": "80320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 157, "minimum": 157 } ] }, { "description": "SURESWAB, TRICHOMONAS VAGINALIS RNA, QUALITATIVE, TMA", "code_information": [ { "code": "87661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 238, "minimum": 238 } ] }, { "description": "PROBNP-NT -- QUEST", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "ESTRADIOL", "code_information": [ { "code": "82670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 229, "minimum": 229 } ] }, { "description": "LH (LUTEINIZING HORMONE)", "code_information": [ { "code": "83002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 194, "minimum": 194 } ] }, { "description": "HEPATITIS B SURFACE ANTIBODY, QUALITATIVE", "code_information": [ { "code": "86706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "CA 27.29", "code_information": [ { "code": "86300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 202, "minimum": 202 } ] }, { "description": "HERPES SIMPLEX VIRUS (HSV2) IGG", "code_information": [ { "code": "86696", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 143, "minimum": 143 } ] }, { "description": "HERPES SIMPLEX VIRUS (HSV 2)", "code_information": [ { "code": "86696", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 143, "minimum": 143 } ] }, { "description": "HERPES SIMPLEX VIRUS (HSV 1)", "code_information": [ { "code": "86695", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 41, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 117, "minimum": 117 } ] }, { "description": "HCG, TOTAL, QUANTITATIVE", "code_information": [ { "code": "84702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 183, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 210, "minimum": 210 } ] }, { "description": "VALPROIC ACID", "code_information": [ { "code": "80164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 192, "minimum": 192 } ] }, { "description": "PROLACTIN", "code_information": [ { "code": "84146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "HEPATITIS A IGM ANTIBODY", "code_information": [ { "code": "86709", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 141, "minimum": 141 } ] }, { "description": "CALPROTECTIN, STOOL", "code_information": [ { "code": "83993", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 254, "minimum": 254 } ] }, { "description": "CRP-HS (HIGH SENSITIVITY)", "code_information": [ { "code": "86141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "HEPATITIS C ANTIBODY", "code_information": [ { "code": "86803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 125, "minimum": 125 } ] }, { "description": "FSH (FOLLICLE STIMULATING HORMONE)", "code_information": [ { "code": "83001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 187, "minimum": 187 } ] }, { "description": "HEPATITIS PROFILE", "code_information": [ { "code": "86706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 112, "minimum": 112 } ] }, { "description": "CHLAMYDIA TRACHOMATIS RNA, TMA", "code_information": [ { "code": "87491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 301, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 317, "minimum": 317 } ] }, { "description": "NEISSERIA GONORRHOEAE RNA, TMA", "code_information": [ { "code": "87591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 304, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 285, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 327, "minimum": 327 } ] }, { "description": "QUANTIFERON TB GOLD", "code_information": [ { "code": "86480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 366, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 358, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 335, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 385, "minimum": 385 } ] }, { "description": "FERRITIN", "code_information": [ { "code": "82728", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "T3 FREE", "code_information": [ { "code": "84481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 209, "minimum": 209 } ] }, { "description": "PTH, INTACT AND CALCIUM 2", "code_information": [ { "code": "83970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 312, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 358, "minimum": 358 } ] }, { "description": "PTH, INTACT AND CALCIUM 1", "code_information": [ { "code": "82310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 68, "minimum": 68 } ] }, { "description": "CULTURE, AEROBIC AND ANAEROBIC", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "ANA IFA SCREEN W/REFLEX TO TITER AND PATTERN, IFA", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "TESTOSTERONE, TOTAL, LC/MS/MS", "code_information": [ { "code": "84403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 231, "minimum": 231 } ] }, { "description": "FOLATE", "code_information": [ { "code": "82746", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 143, "minimum": 143 } ] }, { "description": "VITAMIN B12", "code_information": [ { "code": "82607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 190, "minimum": 190 } ] }, { "description": "LEUKEMIA/LYMPHONA EVALUATION", "code_information": [ { "code": "88185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "PSA, TOTAL", "code_information": [ { "code": "84153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "PSA, FREE", "code_information": [ { "code": "84154", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 179, "minimum": 179 } ] }, { "description": "THYROID PEROXIDASE AND THYROGLOBULIN ANTIBODIES -- QUEST (CPT 86800)", "code_information": [ { "code": "86800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "THYROID PEROXIDASE AND THYROGLOBULIN ANTIBODIES -- QUEST (CPT 86376)", "code_information": [ { "code": "86376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 123, "minimum": 123 } ] }, { "description": "LITHIUM", "code_information": [ { "code": "80178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "COPPER", "code_information": [ { "code": "82525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 56, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 160, "minimum": 160 } ] }, { "description": "SM ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 183, "minimum": 183 } ] }, { "description": "PHENYTOIN", "code_information": [ { "code": "80185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "CULTURE, AEROBIC BACTERIA W/ GRAM STAIN", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "T3 UPTAKE", "code_information": [ { "code": "84479", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "MITOCHONDRIAL M2 ANTIBODY (IGG) -- QUEST", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "PROTEIN S ACTIVITY", "code_information": [ { "code": "85306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 240, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 275, "minimum": 275 } ] }, { "description": "VITAMIN E (TOCOPHEROL)", "code_information": [ { "code": "84446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 154, "minimum": 154 } ] }, { "description": "LUPUS ANTICOAGULANT EVALUATION (PTT-LA)", "code_information": [ { "code": "85613", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 171, "minimum": 171 } ] }, { "description": "LUPUS ANTICOAGULANT EVALUATION (DRVVT)", "code_information": [ { "code": "85613", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 171, "minimum": 171 } ] }, { "description": "CREATININE, RANDOM URINE", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "ABO GROUP AND RH TYPE", "code_information": [ { "code": "86900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 109, "minimum": 109 } ] }, { "description": "JAK2 V617F MUTATION, QUANTITATIVE", "code_information": [ { "code": "81270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 738, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 738, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 738, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 723, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 677, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 272, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 777, "minimum": 777 } ] }, { "description": "CARBAMAZEPINE, TOTAL", "code_information": [ { "code": "80156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 194, "minimum": 194 } ] }, { "description": "TESTOSTERONE, FREE, BIOAVAILABLE AND TOTAL, LC/MS/MS 3", "code_information": [ { "code": "84403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 223, "minimum": 223 } ] }, { "description": "ANCA VASCULITIDES(NEUTROPHIL CYTOPLASMIC ANTIBODIES)", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 216, "minimum": 216 } ] }, { "description": "TESTOSTERONE, FREE, BIOAVAILABLE AND TOTAL, LC/MS/MS 2", "code_information": [ { "code": "84270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 207, "minimum": 207 } ] }, { "description": "LYME DISEASE AB WITH REFLEX TO BLOT(IGG,IGM) -- QUEST -- CPT 86617", "code_information": [ { "code": "86617", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 165, "minimum": 165 } ] }, { "description": "HERPES SIMPLEX VIRUS CULTURE WITH REFLEX TYPING -- QUEST", "code_information": [ { "code": "87255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 245, "minimum": 245 } ] }, { "description": "ACTIN (SMOOTH MUSCLE) ANTIBODY (IGG)", "code_information": [ { "code": "83516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 131, "minimum": 131 } ] }, { "description": "INTRINSIC FACTOR BLOCKING ANTIBODY -- QUEST", "code_information": [ { "code": "86340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "APOLIPOPROTEIN B", "code_information": [ { "code": "82172", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 137, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 125, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 144, "minimum": 144 } ] }, { "description": "KAPPA/LAMBDA LIGHT CHAINS, TOTAL, RANDOM URINE 2", "code_information": [ { "code": "83883", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "FACTOR V ACTIVITY, CLOTTING -- QUEST", "code_information": [ { "code": "85220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 310, "minimum": 310 } ] }, { "description": "PORPHYRINS, FRACTIONATED, QUANTITATIVE, 24-HOUR URINE", "code_information": [ { "code": "84120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 130, "minimum": 130 } ] }, { "description": "CRYPTOSPORIDIUM ANTIGEN, EIA -- QUEST", "code_information": [ { "code": "87328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 150, "minimum": 150 } ] }, { "description": "PROINSULIN", "code_information": [ { "code": "84206", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 214, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 209, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 225, "minimum": 225 } ] }, { "description": "LYME DISEASE AB WITH REFLEX TO BLOT(IGG,IGM) -- QUEST -- CPT 86618", "code_information": [ { "code": "86618", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 175, "minimum": 175 } ] }, { "description": "SURESWAB, VAGINOSIS/VAGINITIS PLUS", "code_information": [ { "code": "87481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 504, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 493, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 530, "minimum": 530 } ] }, { "description": "BORDETELLA PERTUSSIS/PARAPERTUSSIS DNA, QUALITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 291, "minimum": 291 } ] }, { "description": "METANEPHRINES, FRACTIONATED, FREE, LC/MS/MS, PLASMA", "code_information": [ { "code": "83835", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 201, "minimum": 201 } ] }, { "description": "GASTRIN", "code_information": [ { "code": "82941", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 187, "minimum": 187 } ] }, { "description": "TESTOSTERONE, TOTAL, IMMUNOASSAY", "code_information": [ { "code": "84403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 194, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 223, "minimum": 223 } ] }, { "description": "THYROID CANCER (THYROGLOBULIN) MONITOR", "code_information": [ { "code": "86800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 149, "minimum": 149 } ] }, { "description": "HERPES SIMPLEX VIRUS 1/2 ANTIBODY (IGM), IFA W/ REFLEX TO TITER -- QUEST -- CPT 86696", "code_information": [ { "code": "86696", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 148, "minimum": 148 } ] }, { "description": "MERCURY,24 HOUR URINE", "code_information": [ { "code": "83825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 149, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 171, "minimum": 171 } ] }, { "description": "HERPES SIMPLEX VIRUS CULTURE", "code_information": [ { "code": "87255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 228, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 245, "minimum": 245 } ] }, { "description": "CREATININE, 24-HR URINE", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "PROTEIN ELECTROPHORESIS, 24-HOUR URINE (UPEP) 1", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "ESTRIOL", "code_information": [ { "code": "82677", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 184, "minimum": 184 } ] }, { "description": "BETA-HYDROXYBUTYRATE", "code_information": [ { "code": "82010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 122, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 140, "minimum": 140 } ] }, { "description": "CARBOXYHEMOGLOBIN, BLOOD", "code_information": [ { "code": "82375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 134, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 154, "minimum": 154 } ] }, { "description": "PORPHYRINS, TOTAL", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 211, "minimum": 211 } ] }, { "description": "DIRECT LDL", "code_information": [ { "code": "83721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 99, "minimum": 99 } ] }, { "description": "HERPES SIMPLEX VIRUS 1/2 ANTIBODY (IGM), IFA W/ REFLEX TO TITER -- QUEST -- CPT 86695", "code_information": [ { "code": "86695", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 112, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 120, "minimum": 120 } ] }, { "description": "ALKALINE PHOSPHATASE ISOENZYMES 2", "code_information": [ { "code": "84080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 124, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 130, "minimum": 130 } ] }, { "description": "ALLERGEN COW\u0027S MILK (F2) IGE", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "PARSLEY (IGE) SERUM", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "DILL (IGE) SERUM", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "PINEAPPLE (IGE) SERUM", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "THYME (IGE) SERUM", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "BANANA (IGE) SERUM", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "SODIUM, 24-HOUR URINE WITHOUT CREATININE", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 52, "minimum": 52 } ] }, { "description": "SCREEN FOR MRSA", "code_information": [ { "code": "87081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 124, "minimum": 124 } ] }, { "description": "PROTEIN ELECTROPHORESIS, 24-HOUR URINE (UPEP) 2", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 90, "minimum": 90 } ] }, { "description": "SARS-COV-2(COVID-19)AB(IGG,IGM) -- QUEST 31672 -- CPT 86769", "code_information": [ { "code": "86769", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 123, "minimum": 123 } ] }, { "description": "DRUGS OF ABUSE SCREEN – PAIN MANAGEMENT – MGGH LAB", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "TOTAL BILIRUBIN", "code_information": [ { "code": "82247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "VANCOMYCIN PEAK", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "PHENYTOIN (IN-HOUSE)", "code_information": [ { "code": "80185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 172, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 198, "minimum": 198 } ] }, { "description": "ALK. PHOS.", "code_information": [ { "code": "84075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 55, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 63, "minimum": 63 } ] }, { "description": "TRIGLYCERIDES", "code_information": [ { "code": "84478", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 70, "minimum": 70 } ] }, { "description": "POTASSIUM", "code_information": [ { "code": "84132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 52, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 56, "minimum": 56 } ] }, { "description": "GLUCOSE, FASTING", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "ARTERIAL BLOOD GASES -- MGGH LAB (EPOC)", "code_information": [ { "code": "82803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 313, "minimum": 313 } ] }, { "description": "VANCOMYCIN TROUGH", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "AST (SGOT)", "code_information": [ { "code": "84450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "ALT (SGPT)", "code_information": [ { "code": "84460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": "OVA AND PARASITES", "code_information": [ { "code": "87177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 99, "minimum": 99 } ] }, { "description": "DIRECT BILIRUBIN", "code_information": [ { "code": "82248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 50, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 57, "minimum": 57 } ] }, { "description": "CREATININE", "code_information": [ { "code": "82565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 70, "minimum": 70 } ] }, { "description": "HIV ANTIBODY DIFFERENTIATION", "code_information": [ { "code": "87535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 413, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 387, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 444, "minimum": 444 } ] }, { "description": "ANTIBODY SCREEN", "code_information": [ { "code": "86850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 163, "minimum": 163 } ] }, { "description": "RH BLOOD TYPING", "code_information": [ { "code": "86901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "ABO BLOOD TYPING", "code_information": [ { "code": "86900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 109, "minimum": 109 } ] }, { "description": "CALCIUM TOTAL", "code_information": [ { "code": "82310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 68, "minimum": 68 } ] }, { "description": "ALBUMIN", "code_information": [ { "code": "82040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 67, "minimum": 67 } ] }, { "description": "PSA DIAGNOSTIC", "code_information": [ { "code": "84153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 166, "minimum": 166 } ] }, { "description": "RSV", "code_information": [ { "code": "86756", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 165, "minimum": 165 } ] }, { "description": "HEMATOCRIT", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "HEMOGLOBIN", "code_information": [ { "code": "85018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "STREP", "code_information": [ { "code": "86063", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "URINE DRUG COLLECTION A", "code_information": [ { "code": "99001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 87, "minimum": 87 } ] }, { "description": "LIPASE", "code_information": [ { "code": "83690", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 110, "minimum": 110 } ] }, { "description": "GLUCOSE BLOOD", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "CK-MB", "code_information": [ { "code": "82553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 180, "minimum": 180 } ] }, { "description": "MONO SPOT TEST", "code_information": [ { "code": "86308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 94, "minimum": 94 } ] }, { "description": "VANCOMYCIN RANDOM", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "SPUTUM CULTURE", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 103, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 111, "minimum": 111 } ] }, { "description": "PLATELET COUNT", "code_information": [ { "code": "85027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 92, "minimum": 92 } ] }, { "description": "CHOLESTEROL", "code_information": [ { "code": "82465", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 69, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 74, "minimum": 74 } ] }, { "description": "CLOSTRIDIUM DIFFICILE", "code_information": [ { "code": "87081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 118, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 115, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 108, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 124, "minimum": 124 } ] }, { "description": "SCANNING ANALYSIS W/RPT", "code_information": [ { "code": "93226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 540, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 528, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 495, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 568, "minimum": 568 } ] }, { "description": "HOLTER MONITOR", "code_information": [ { "code": "93225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 453, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 453, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 453, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 444, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 415, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 477, "minimum": 477 } ] }, { "description": "EKG SERIAL", "code_information": [ { "code": "93000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 249, "minimum": 249 } ] }, { "description": "CTA LT LEG W/IV", "code_information": [ { "code": "73706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2852, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2852, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2852, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2792, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2615, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1051, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3002, "minimum": 3002 } ] }, { "description": "PELVIS WO/W CONTRAST", "code_information": [ { "code": "72194", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3096, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3096, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3096, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3031, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2839, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3259, "minimum": 3259 } ] }, { "description": "UPPER EXTREMITY RT W C", "code_information": [ { "code": "73201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2281, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2453, "minimum": 2453 } ] }, { "description": "ABDOMEN W/O CONTRAST", "code_information": [ { "code": "74150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1916, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1916, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1916, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1876, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1757, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2017, "minimum": 2017 } ] }, { "description": "HEAD WO/W CONTRAST", "code_information": [ { "code": "70470", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2550, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2496, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2338, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 939, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 939, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 939, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 939, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 939, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2684, "minimum": 2684 } ] }, { "description": "ABDOMEN WO/W CONTRAST", "code_information": [ { "code": "74170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2513, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2513, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2513, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2460, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2304, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 926, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 926, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 926, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 926, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 926, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2645, "minimum": 2645 } ] }, { "description": "PELVIS W/O CONTRAST", "code_information": [ { "code": "72192", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1980, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1980, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1980, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1938, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1815, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2084, "minimum": 2084 } ] }, { "description": "MAXILLOFACIAL W/O C", "code_information": [ { "code": "70486", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1928, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1928, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1928, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1887, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1767, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 710, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 710, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 710, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 710, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 710, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2029, "minimum": 2029 } ] }, { "description": "ORBIT SELLA FOSSA EAR W/O", "code_information": [ { "code": "70480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1890, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1890, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1890, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1850, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1732, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 696, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 696, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 696, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 696, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 696, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1989, "minimum": 1989 } ] }, { "description": "ORBITS W CONTRAST", "code_information": [ { "code": "70481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2163, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2026, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 814, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 814, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 814, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 814, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 814, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2326, "minimum": 2326 } ] }, { "description": "HEAD WITH CONTRAST", "code_information": [ { "code": "70460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2263, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2263, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2263, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2215, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2075, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 834, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2382, "minimum": 2382 } ] }, { "description": "UPPER EXTREMITY LT W C", "code_information": [ { "code": "73201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2281, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2137, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 859, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2453, "minimum": 2453 } ] }, { "description": "REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP (PICC LINE REMOVAL)", "code_information": [ { "code": "36590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2604, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2439, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2800, "minimum": 2800 } ] }, { "description": "REPAIR SIMPLE 7.6-12.5 CM", "code_information": [ { "code": "12015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 670, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 670, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 670, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 614, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 705, "minimum": 705 } ] }, { "description": "REPAIR SIMPLE 7.6-12.5 CM", "code_information": [ { "code": "12015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 605, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 695, "minimum": 695 } ] }, { "description": "I\u0026D VULVA/PERINEAL ABCESS", "code_information": [ { "code": "56405", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 810, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 810, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 810, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 743, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 853, "minimum": 853 } ] }, { "description": "I\u0026D VULVA/PERINEAL ABCESS", "code_information": [ { "code": "56405", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 519, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 519, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 519, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 476, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 191, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 546, "minimum": 546 } ] }, { "description": "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE", "code_information": [ { "code": "25605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2330, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2182, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 877, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 877, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 877, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 877, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 877, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2505, "minimum": 2505 } ] }, { "description": "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE", "code_information": [ { "code": "25605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2688, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2688, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2688, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2632, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2465, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 991, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 991, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 991, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 991, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 991, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2830, "minimum": 2830 } ] }, { "description": "CLOSED TRET SHLD DISLOC", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1114, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1091, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1022, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1173, "minimum": 1173 } ] }, { "description": "CLOSED TRET SHLD DISLOC *", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1149, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1124, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1053, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1209, "minimum": 1209 } ] }, { "description": "PHALANGEL SHAFT W/O MAL", "code_information": [ { "code": "26720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 587, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 587, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 587, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 575, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 538, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 216, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 618, "minimum": 618 } ] }, { "description": "PHALANGEL SHAFT W/O MAL", "code_information": [ { "code": "26720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 632, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 632, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 632, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 618, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 579, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 665, "minimum": 665 } ] }, { "description": "INSERT CENTRL VENOUS CATH", "code_information": [ { "code": "36556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2068, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 831, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 831, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 831, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 831, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 831, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2374, "minimum": 2374 } ] }, { "description": "INSERT CENTRL VENOUS CATH", "code_information": [ { "code": "36556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 704, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 704, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 704, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 689, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 645, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 741, "minimum": 741 } ] }, { "description": "THER ADDL DRUG X1 ONLY", "code_information": [ { "code": "96367", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 351, "minimum": 351 } ] }, { "description": "THER ADDL DRUG X1 ONLY", "code_information": [ { "code": "96367", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 351, "minimum": 351 } ] }, { "description": "IV PUSH SAME SUBSTANCE", "code_information": [ { "code": "96376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "THERAPEUTIC 16-60 MIN", "code_information": [ { "code": "96365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 576, "minimum": 576 } ] }, { "description": "THER. EA ADD HR\u003e30MIN", "code_information": [ { "code": "96366", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "HYDRA EA AD HR\u003e30 MIN", "code_information": [ { "code": "96361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "REPAIR SIMPLE 5.1-7.5 CM", "code_information": [ { "code": "12014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 717, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 702, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 658, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 755, "minimum": 755 } ] }, { "description": "FOREIGN BODY CORNEAL", "code_information": [ { "code": "65220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 560, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 560, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 560, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 549, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 514, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 590, "minimum": 590 } ] }, { "description": "I\u0026D DEEP ABSCESS", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 600, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 600, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 600, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 588, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 550, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 632, "minimum": 632 } ] }, { "description": "REPAIR SIMPLE 2.6-5.0 CM", "code_information": [ { "code": "12013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 582, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 582, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 582, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 613, "minimum": 613 } ] }, { "description": "CARDIOPULMONARY RESUSCITATION", "code_information": [ { "code": "92950", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1115, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1280, "minimum": 1280 } ] }, { "description": "PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION", "code_information": [ { "code": "36680", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 466, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 535, "minimum": 535 } ] }, { "description": "INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE", "code_information": [ { "code": "51702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 324, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 297, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 119, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 341, "minimum": 341 } ] }, { "description": "REPAIR SIMPLE \u003c2.5 CM*", "code_information": [ { "code": "12011", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 509, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 509, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 509, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 467, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 536, "minimum": 536 } ] }, { "description": "IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS", "code_information": [ { "code": "96368", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 182, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 167, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 67, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 192, "minimum": 192 } ] }, { "description": "REPAIR SUP WOUNDS \u003c2.5CM", "code_information": [ { "code": "12001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 485, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 475, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 445, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 511, "minimum": 511 } ] }, { "description": "IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR", "code_information": [ { "code": "96360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 488, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 478, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 514, "minimum": 514 } ] }, { "description": "IMADM PRQ ID SUBQ/IM NJXS 1 VACCINE", "code_information": [ { "code": "90471", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 40, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 115, "minimum": 115 } ] }, { "description": "IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR", "code_information": [ { "code": "96367", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 326, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 123, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 351, "minimum": 351 } ] }, { "description": "THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC", "code_information": [ { "code": "96376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 200, "minimum": 200 } ] }, { "description": "IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR", "code_information": [ { "code": "96366", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG", "code_information": [ { "code": "96374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 311, "minimum": 311 } ] }, { "description": "IV INFUSION HYDRATION EACH ADDITIONAL HOUR", "code_information": [ { "code": "96361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 203, "minimum": 203 } ] }, { "description": "IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR", "code_information": [ { "code": "96365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 576, "minimum": 576 } ] }, { "description": "EMERGENCY DEPT VISIT HIGH SEVERITY\u0026THREAT FUNCJ", "code_information": [ { "code": "99285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2185, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2046, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 822, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 822, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 822, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 822, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 822, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2349, "minimum": 2349 } ] }, { "description": "THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "IM OR SUBQ INJ", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "THER INJ, IM OR SUBQ", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 146, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 168, "minimum": 168 } ] }, { "description": "IV PUSH NEW SUBSTANCE", "code_information": [ { "code": "96375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG", "code_information": [ { "code": "96375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "CLOSED T/X,RADIAL FRACTUR", "code_information": [ { "code": "25600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1222, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1222, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1222, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1196, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 450, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1286, "minimum": 1286 } ] }, { "description": "REPAIR COMPLEX,2.6-7.5 CM", "code_information": [ { "code": "13132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1827, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1711, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 687, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 687, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 687, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 687, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 687, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1964, "minimum": 1964 } ] }, { "description": "APPLIC. LONG ARM SPLINT", "code_information": [ { "code": "29105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 459, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 459, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 459, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 449, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 483, "minimum": 483 } ] }, { "description": "CONTROL NASAL HEMMOR SMP", "code_information": [ { "code": "30901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 436, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 427, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 459, "minimum": 459 } ] }, { "description": "REPAIR WOUND 7.6-12.5 CM", "code_information": [ { "code": "12004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 642, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 601, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 690, "minimum": 690 } ] }, { "description": "LAYER CLOSURE 2.6-7.5 CM", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 894, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 875, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 820, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 329, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 941, "minimum": 941 } ] }, { "description": "CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE; W/O MANIPULATION", "code_information": [ { "code": "27786", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 776, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 776, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 776, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 760, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 712, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 817, "minimum": 817 } ] }, { "description": "REPAIR COMP,CHIN 1.1-2.5", "code_information": [ { "code": "13131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1094, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1094, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1094, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1071, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1003, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 403, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1152, "minimum": 1152 } ] }, { "description": "EXCISE,NAIL PART/COMPLETE", "code_information": [ { "code": "11750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1087, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1087, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1087, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1064, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 996, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1144, "minimum": 1144 } ] }, { "description": "REPAIR COMP.\u003c=5CM, EA ADD", "code_information": [ { "code": "13122", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1022, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1022, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1022, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1001, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 937, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1076, "minimum": 1076 } ] }, { "description": "LAYER CLOSURE \u003c2.5 CM", "code_information": [ { "code": "12031", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 804, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 804, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 804, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 787, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 737, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 846, "minimum": 846 } ] }, { "description": "ASPIRATION OF ABCESS", "code_information": [ { "code": "10160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 715, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 715, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 715, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 700, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 753, "minimum": 753 } ] }, { "description": "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS", "code_information": [ { "code": "10120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1359, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1331, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1246, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 501, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 501, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 501, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 501, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 501, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1431, "minimum": 1431 } ] }, { "description": "CTR NASAL HEMMOR.PACK/CA", "code_information": [ { "code": "30905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 570, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 558, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 523, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 600, "minimum": 600 } ] }, { "description": "CLOSED TREATMENT OF KNEE DISLOCATION: WITHOUT ANESTHESIA", "code_information": [ { "code": "27550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1692, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1692, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1692, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1656, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1551, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 623, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 623, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 623, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 623, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 623, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1781, "minimum": 1781 } ] }, { "description": "LAYER CLOSURE, 5.1-7.5 CM", "code_information": [ { "code": "12053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 902, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 902, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 902, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 883, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 827, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 949, "minimum": 949 } ] }, { "description": "LAYER CLOSURE 7.6-12.5CM", "code_information": [ { "code": "12044", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 882, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 882, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 882, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 863, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 808, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 928, "minimum": 928 } ] }, { "description": "PERITONEOCENTESIS,ABD/PE", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1979, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1979, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1979, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1937, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1814, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2083, "minimum": 2083 } ] }, { "description": "REPAIR,COMPLX,ADDL,\u003c=5CM", "code_information": [ { "code": "13133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1054, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1054, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1054, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1031, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 966, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 388, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1109, "minimum": 1109 } ] }, { "description": "INCISION EXT HEMORRHOID", "code_information": [ { "code": "46083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 949, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 949, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 949, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 929, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 870, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 999, "minimum": 999 } ] }, { "description": "PERICARDIOCENTESIS, INCLUDING IMAGING GUIDE, WHEN PERFORMED", "code_information": [ { "code": "33016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2290, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2100, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2411, "minimum": 2411 } ] }, { "description": "MODERATE SEDATION, \u003e 5 YO, FIRST 30 MINUTES INTRA-SERVICE TIME", "code_information": [ { "code": "99151", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 451, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 485, "minimum": 485 } ] }, { "description": "ABDOMINAL PARACENTESIS WITH IMAGING GUIDANCE", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 3125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 3125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 3125, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 3059, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 2865, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 3289, "minimum": 3289 } ] }, { "description": "FRACTURE AND/OR DISLOCATION PROCEDURE ON THE FOREARM AND WRIST", "code_information": [ { "code": "25650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1087, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1087, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1087, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1064, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 996, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1144, "minimum": 1144 } ] }, { "description": "LAYER CLOSURE 12.6-20 CM", "code_information": [ { "code": "12035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1010, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1010, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1010, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 989, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 926, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1063, "minimum": 1063 } ] }, { "description": "CLOSED TREATMENT OF CLAVICULAR FRACTURE, W/O MANIPULATION", "code_information": [ { "code": "23500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 702, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 702, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 702, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 687, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 644, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 739, "minimum": 739 } ] }, { "description": "FRACTURE AND/OR DISCLOCATION PROCEDURE ON THE LEG (TIBIA \u0026 FIBULA \u0026 ANKLE JOINT)", "code_information": [ { "code": "27750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 819, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 767, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 881, "minimum": 881 } ] }, { "description": "PRO FEES FRACTURE AND/OR DISLOCATION PROCEDURE ON THE LEG (TIBIA \u0026 FIBULA) \u0026 ANKLE JOINT.", "code_information": [ { "code": "27750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 819, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 767, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 881, "minimum": 881 } ] }, { "description": "AVUL, NAIL PLATE, 1 SIMP", "code_information": [ { "code": "11730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 590, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 590, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 590, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 578, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 541, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 621, "minimum": 621 } ] }, { "description": "Closed treatment of proximal fibula or shaft fracture", "code_information": [ { "code": "27780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 598, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 598, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 598, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 549, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 630, "minimum": 630 } ] }, { "description": "LAYER CLOSURE 2.6-5.0 CM", "code_information": [ { "code": "12052", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 883, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 883, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 883, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 864, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 809, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 325, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 929, "minimum": 929 } ] }, { "description": "PRO FEES CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE W/O MANIPULATION.", "code_information": [ { "code": "27780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 598, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 598, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 598, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 586, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 549, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 630, "minimum": 630 } ] }, { "description": "CLOSED TX ULNAR FRACTURE", "code_information": [ { "code": "24670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 481, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 471, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 441, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 177, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 506, "minimum": 506 } ] }, { "description": "DEBRIDEMENT, OPEN WOUND, FIRST 20 SQ CM OR LESS", "code_information": [ { "code": "97597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 334, "minimum": 334 } ] }, { "description": "I\u0026D PILONIDAL CYST", "code_information": [ { "code": "10080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 612, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 612, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 612, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 599, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 561, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 225, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 644, "minimum": 644 } ] }, { "description": "I\u0026D BARTHOLIN GLAND ABSCE", "code_information": [ { "code": "56420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 597, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 597, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 597, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 584, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 547, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 220, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 628, "minimum": 628 } ] }, { "description": "ELECTRICAL STIMULATION, ATTENDED", "code_information": [ { "code": "G0283", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "TRYPTASE", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "ANTI-MULLERIAN HOROMONE (FEMALE) -- QUEST", "code_information": [ { "code": "83520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 226, "minimum": 226 } ] }, { "description": "TRICHOMONAS VAGINALIS RNA, QUALITATIVE, TMA, MALES", "code_information": [ { "code": "87661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 238, "minimum": 238 } ] }, { "description": "HCV RNA NS3 GENOTYPE", "code_information": [ { "code": "87902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 903, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 903, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 903, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 884, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 827, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 950, "minimum": 950 } ] }, { "description": "CHROMOSOME ANALYSIS, BLOOD -- QUEST 14596 -- CPT 88230", "code_information": [ { "code": "88230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 747, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 747, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 747, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 731, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 685, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 786, "minimum": 786 } ] }, { "description": "CLOSTRIDIUM DIFFICILE TOXIN B, QUALITATIVE, REAL-TIME PCR", "code_information": [ { "code": "87493", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 227, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 244, "minimum": 244 } ] }, { "description": "17-HYDROXYPREGNENOLONE, LC/MS/MS", "code_information": [ { "code": "84143", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 281, "minimum": 281 } ] }, { "description": "CHROMOSOME ANALYSIS, BLOOD -- QUEST 14596 -- CPT 88262", "code_information": [ { "code": "88262", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 903, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 903, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 903, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 884, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 827, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 333, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 950, "minimum": 950 } ] }, { "description": "VON WILLEBRAND FACTOR ANTIGEN", "code_information": [ { "code": "85246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 264, "minimum": 264 } ] }, { "description": "PAIN MANAGEMENT SCREENING PROFILE, URINE -- LABCORP", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 294, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 316, "minimum": 316 } ] }, { "description": "ANCA SCREEN WITH REFLEX TO ANCA TITER", "code_information": [ { "code": "86021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 188, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 216, "minimum": 216 } ] }, { "description": "inFLIXmimab 10mg IV", "drug_information": { "unit": "100", "type": "GR" }, "code_information": [ { "code": "57894016001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Helicobacter pylori, Urea Breath Test", "code_information": [ { "code": "83013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 473, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 463, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 434, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 498, "minimum": 498 } ] }, { "description": "IRON AND TOTAL IRON BINDING CAPACITY (TIBC) -- LABCORP -- CPT 83550", "code_information": [ { "code": "83550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 90, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 95, "minimum": 95 } ] }, { "description": "IRON AND TOTAL IRON BINDING CAPACITY (TIBC) -- LABCORP -- CPT 83540", "code_information": [ { "code": "83540", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 85, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 89, "minimum": 89 } ] }, { "description": "STOOL CULTURE", "code_information": [ { "code": "87045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 161, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 173, "minimum": 173 } ] }, { "description": "IGA, SERUM", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 84, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 31, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 88, "minimum": 88 } ] }, { "description": "STOOL FOR WBC", "code_information": [ { "code": "89055", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "CREATININE CLEARANCE", "code_information": [ { "code": "82575", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 152, "minimum": 152 } ] }, { "description": "LEUKEMIA/LYMPHONA EVALUATION", "code_information": [ { "code": "88189", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 266, "minimum": 266 } ] }, { "description": "CYSTIC FIBROSIS SCREEN", "code_information": [ { "code": "81220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 784, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 900, "minimum": 900 } ] }, { "description": "TRACHEOSTOMY, EMERGENCY PROCEDURE, CRICOTHYROID -- PRO FEES", "code_information": [ { "code": "31605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1014, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 992, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 929, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 373, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1067, "minimum": 1067 } ] }, { "description": "ER VISIT,FOCUSED,PRO FEE", "code_information": [ { "code": "99281,PF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 155, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 167, "minimum": 167 } ] }, { "description": "ADM/DC SAME DAY-HIGH OBS", "code_information": [ { "code": "99236", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 901, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 901, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 901, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 882, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 826, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 332, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 948, "minimum": 948 } ] }, { "description": "REPAIR COMP. 2.6CM-7.5CM", "code_information": [ { "code": "13121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1496, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1465, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1372, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 551, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 551, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 551, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 551, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 551, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1575, "minimum": 1575 } ] }, { "description": "CRITCARE, 1ST HR, IP PF", "code_information": [ { "code": "99291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1321, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1420, "minimum": 1420 } ] }, { "description": "CRITCARE,1ST HR,PROFEE", "code_information": [ { "code": "99291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1321, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1420, "minimum": 1420 } ] }, { "description": "ADM/DC SAME DAY-LOW IP", "code_information": [ { "code": "99234", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 402, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 432, "minimum": 432 } ] }, { "description": "ADM/DC SAME DAY-LOW OBS", "code_information": [ { "code": "99234", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 402, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 432, "minimum": 432 } ] }, { "description": "HOSP DISCHARGE \u003e30 MIN", "code_information": [ { "code": "99239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 298, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 314, "minimum": 314 } ] }, { "description": "ADM/DC SAME DAY-MOD IP", "code_information": [ { "code": "99235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 664, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 762, "minimum": 762 } ] }, { "description": "ADM/DC SAME DAY-MOD OBS", "code_information": [ { "code": "99235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 724, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 709, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 664, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 762, "minimum": 762 } ] }, { "description": "CRITCARE,ADD 30MIN,PROFEE", "code_information": [ { "code": "99292", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 556, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 556, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 556, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 544, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 510, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 205, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 585, "minimum": 585 } ] }, { "description": "HOSP CARE,ADMIT,INIT,HIGH", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 458, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 526, "minimum": 526 } ] }, { "description": "HOSP VISIT,SUBSEQ,HIGH", "code_information": [ { "code": "99233", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 357, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 327, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 376, "minimum": 376 } ] }, { "description": "ER VISIT,COMP,PRO FEE", "code_information": [ { "code": "99285,PF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1045, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1023, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 958, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 385, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1100, "minimum": 1100 } ] }, { "description": "ER VISIT,LOW,PRO FEE", "code_information": [ { "code": "99282,PF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 257, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 252, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 271, "minimum": 271 } ] }, { "description": "ER VISIT,DETAILED,PRO FEE", "code_information": [ { "code": "99284,PF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 716, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 716, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 716, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 701, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 657, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 264, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 754, "minimum": 754 } ] }, { "description": "ER VISIT,MOD,PRO FEE", "code_information": [ { "code": "99283,PF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 451, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 451, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 451, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 414, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 166, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 475, "minimum": 475 } ] }, { "description": "APPLY SPLINT, SHORT ARM", "code_information": [ { "code": "29125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 230, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 215, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 86, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 247, "minimum": 247 } ] }, { "description": "LAYER CLOSURE 2.6-7.5 CM", "code_information": [ { "code": "12042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 720, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 720, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 720, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 705, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 758, "minimum": 758 } ] }, { "description": "APPLY SHORT LEG SPLINT", "code_information": [ { "code": "29515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 268, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 268, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 268, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 262, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 282, "minimum": 282 } ] }, { "description": "LAYER CLOSURE \u003c2.5CM*", "code_information": [ { "code": "12041", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 614, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 575, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 660, "minimum": 660 } ] }, { "description": "CLSD TXT RADIAL/ULNR FRAC", "code_information": [ { "code": "25560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 935, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 935, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 935, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 915, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 857, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 344, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 984, "minimum": 984 } ] }, { "description": "I\u0026D ABCESS,COMP OR MUL", "code_information": [ { "code": "10061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 464, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 454, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 488, "minimum": 488 } ] }, { "description": "SPLINT THIGH TO TOES", "code_information": [ { "code": "29505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 281, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 281, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 281, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 104, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 296, "minimum": 296 } ] }, { "description": "LAYER CLOSURE \u003c2.5CM*", "code_information": [ { "code": "12051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 677, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 677, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 677, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 663, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 621, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 713, "minimum": 713 } ] }, { "description": "INCISION SOFT TISS ABSCES", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 342, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 368, "minimum": 368 } ] }, { "description": "CONTROL NASAL HEMMOR.COM*", "code_information": [ { "code": "30903", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 416, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 389, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 447, "minimum": 447 } ] }, { "description": "CARDIOVERSION, EXT", "code_information": [ { "code": "92960", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 896, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 896, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 896, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 877, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 821, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 330, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 943, "minimum": 943 } ] }, { "description": "FOREIGN BODY CORNEAL", "code_information": [ { "code": "65220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 235, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 270, "minimum": 270 } ] }, { "description": "I\u0026D DEEP ABSCESS", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 350, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 342, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 368, "minimum": 368 } ] }, { "description": "REMOVE IMPACTED CERUMEN", "code_information": [ { "code": "69210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 178, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 174, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 163, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 187, "minimum": 187 } ] }, { "description": "REPAIR SIMPLE 5.1-7.5 CM", "code_information": [ { "code": "12014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 536, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 491, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 197, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 564, "minimum": 564 } ] }, { "description": "REPAIR SIMPLE 2.6-5.0 CM*", "code_information": [ { "code": "12013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 417, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 417, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 417, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 408, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 382, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 439, "minimum": 439 } ] }, { "description": "CARDIOPULMONARY RESUS", "code_information": [ { "code": "92950", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 986, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 986, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 986, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 965, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 904, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1038, "minimum": 1038 } ] }, { "description": "REPAIR SIMPLE \u003c2.5 CM*", "code_information": [ { "code": "12011", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 458, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 429, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 173, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 493, "minimum": 493 } ] }, { "description": "INTUBATION - PHYS FEE", "code_information": [ { "code": "31500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 646, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 632, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 592, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 680, "minimum": 680 } ] }, { "description": "REPAIR WOUND 2.6-7.5 CM*", "code_information": [ { "code": "12002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 377, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 397, "minimum": 397 } ] }, { "description": "HOSP CARE,ADMIT,INIT,MOD", "code_information": [ { "code": "99222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 380, "minimum": 380 } ] }, { "description": "IP CONSULT LEVEL 4", "code_information": [ { "code": "99222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 353, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 331, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 380, "minimum": 380 } ] }, { "description": "HOSP DISCHARGE \u003c30 MIN", "code_information": [ { "code": "99238", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 314, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 287, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 330, "minimum": 330 } ] }, { "description": "HOSP VISIT,SUBSEQ,MOD.", "code_information": [ { "code": "99232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 217, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 233, "minimum": 233 } ] }, { "description": "CLOSED T/X,RADIAL FRACTUR", "code_information": [ { "code": "25600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 758, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 742, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 695, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 279, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 798, "minimum": 798 } ] }, { "description": "REPAIR COMPLEX,2.6-7.5 CM", "code_information": [ { "code": "13132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1806, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1806, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1806, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1768, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1656, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 665, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1901, "minimum": 1901 } ] }, { "description": "APPLIC. LONG ARM SPLINT", "code_information": [ { "code": "29105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 291, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 334, "minimum": 334 } ] }, { "description": "REPAIR WOUND 7.6-12.5 CM*", "code_information": [ { "code": "12004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 555, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 543, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 509, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 584, "minimum": 584 } ] }, { "description": "LAYER CLOSURE 2.6-7.5 CM*", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 748, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 748, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 748, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 732, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 685, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 275, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 787, "minimum": 787 } ] }, { "description": "CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE; W/O MANIPULATION", "code_information": [ { "code": "27786", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1130, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1058, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 425, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1215, "minimum": 1215 } ] }, { "description": "ESTRONE", "code_information": [ { "code": "82679", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 249, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 233, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 268, "minimum": 268 } ] }, { "description": "TOTAL T3", "code_information": [ { "code": "84480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 133, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 153, "minimum": 153 } ] }, { "description": "THYROID PEROXIDASE ANTIBODIES (TPO)", "code_information": [ { "code": "86376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 117, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 114, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 123, "minimum": 123 } ] }, { "description": "DEXAMETHASONE -- QUEST", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 211, "minimum": 211 } ] }, { "description": "TACROLIMUS (FK506)", "code_information": [ { "code": "80197", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 229, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 263, "minimum": 263 } ] }, { "description": "PROTEIN ELECTROPHORESIS, RANDOM URINE (UPEP) 3 (CREATININE)", "code_information": [ { "code": "84166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 157, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 165, "minimum": 165 } ] }, { "description": "OVERNIGHT OXIMETRY", "code_information": [ { "code": "94762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 644, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 644, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 644, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 631, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 591, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 678, "minimum": 678 } ] }, { "description": "CARDIO PULM RESUSCIT", "code_information": [ { "code": "92950", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1190, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1115, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 448, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1280, "minimum": 1280 } ] }, { "description": "Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed", "code_information": [ { "code": "94618", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 640, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 640, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 640, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 587, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 674, "minimum": 674 } ] }, { "description": "MDI INHALER TX INITIAL", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "MDI INHALER TX SUB", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "AEROSOL TREATMENT INITIAL", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "AEROSOL TREATMENT SUB", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "IPPB TREATMENT SUB", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 207, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 190, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 218, "minimum": 218 } ] }, { "description": "VENTILATOR PER DAY SUBSEQ", "code_information": [ { "code": "94003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2025, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2025, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2025, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1983, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1857, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 746, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2132, "minimum": 2132 } ] }, { "description": "TRACHEOSTOMY, EMERGENCY PROCEDURE, CRICOTHYROID", "code_information": [ { "code": "31605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1505, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1409, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 566, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 566, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 566, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 566, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 566, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1618, "minimum": 1618 } ] }, { "description": "NASO TRACHEAL SUCTION", "code_information": [ { "code": "31720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 670, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 670, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 670, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 656, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 614, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 705, "minimum": 705 } ] }, { "description": "FLUTTER VALVE SUBSEQ", "code_information": [ { "code": "94668", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 189, "minimum": 189 } ] }, { "description": "CHEST PERCUSSION SUB", "code_information": [ { "code": "94668", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 176, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 189, "minimum": 189 } ] }, { "description": "AMBUL BLOOD PRESS MONITOR", "code_information": [ { "code": "93788", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 400, "minimum": 400 } ] }, { "description": "CONT NEBUL THER-ADDL HR", "code_information": [ { "code": "94645", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 295, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 271, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 109, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 311, "minimum": 311 } ] }, { "description": "PFT SIMPLE", "code_information": [ { "code": "94010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 268, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 251, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 288, "minimum": 288 } ] }, { "description": "NO SHOW ECHO", "code_information": [ { "code": "0483", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "NO SHOW ULTRASOUND", "code_information": [ { "code": "0402", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "ACTIVAC CANISTER W/GEL per pc", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12.2, "minimum": 12.2 } ] }, { "description": "TELEMETRY ROOM\t(SEMI-PRIVATE)", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 2154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 2154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 2154, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 2108, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1975, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 793, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2267, "minimum": 2267 } ] }, { "description": "MED/SURG ROOM (PRIVATE)", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1808, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1770, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1658, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 666, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1903, "minimum": 1903 } ] }, { "description": "MINERAL COUNTY FD PHYS \u003e40", "code_information": [ { "code": "99396", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 480, "minimum": 480 } ] }, { "description": "MINERAL COUNTY FD PHYS 65+", "code_information": [ { "code": "99397", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 456, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 446, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 168, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 480, "minimum": 480 } ] }, { "description": "Skin Test: Tuberculosis, Intradermal", "code_information": [ { "code": "86580", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 59, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 58, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 54, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 62, "minimum": 62 } ] }, { "description": "VACCINE ADMIN 1ST", "code_information": [ { "code": "90471", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "VACCINE ADMIN 1ST", "code_information": [ { "code": "90472", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "Ventolin HFA 90 MCG 200 dose", "drug_information": { "unit": "200", "type": "UN" }, "code_information": [ { "code": "00173068220", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OFFICE VISIT,EST,EXPANDED", "code_information": [ { "code": "99213", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 272, "minimum": 272 } ] }, { "description": "OFFICE VISIT,EST,DETAILED", "code_information": [ { "code": "99214", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 367, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 367, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 367, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 359, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 336, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 386, "minimum": 386 } ] }, { "description": "OFFICE VISIT,EST,FOCUSED", "code_information": [ { "code": "99212,OF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "ANNUAL WELLNES SUBS MC", "code_information": [ { "code": "G0439", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "DESTRUCT,LESION,2-14 EACH", "code_information": [ { "code": "17003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 34, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 39, "minimum": 39 } ] }, { "description": "URINALYSIS", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 38, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 14, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 40, "minimum": 40 } ] }, { "description": "OFFICE VISIT,NEW,DETAILED", "code_information": [ { "code": "99203", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 274, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 110, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 315, "minimum": 315 } ] }, { "description": "ADMIN. INF. VACINE", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 47, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 44, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 18, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 51, "minimum": 51 } ] }, { "description": "EPSDT IMMUN ADMIN, 1 VACC", "code_information": [ { "code": "90471", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 83, "minimum": 83 } ] }, { "description": "OFFICE VISIT,NEW,MOD COMP", "code_information": [ { "code": "99204", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 452, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 423, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 170, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 486, "minimum": 486 } ] }, { "description": "ANNUAL WELLNESS FIRST MC", "code_information": [ { "code": "G0438", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 805, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 805, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 805, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 788, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 738, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 847, "minimum": 847 } ] }, { "description": "EPSDT IMMUN ADMIN, EA ADD", "code_information": [ { "code": "90472", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 82, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 86, "minimum": 86 } ] }, { "description": "DESTRUCT,1 LESION BENIGN*", "code_information": [ { "code": "17000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 307, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 281, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 323, "minimum": 323 } ] }, { "description": "HOME VISIT, MOD, EST", "code_information": [ { "code": "99349", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 213, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 208, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 195, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 224, "minimum": 224 } ] }, { "description": "INJ FEE ALLERGY (X1)", "code_information": [ { "code": "95115", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 32, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 34, "minimum": 34 } ] }, { "description": "HOME VISIT, EXPANDED, EST", "code_information": [ { "code": "99348", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 156, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 153, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 164, "minimum": 164 } ] }, { "description": "INJ FEE ALLERGY (X2)", "code_information": [ { "code": "95117", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 45, "minimum": 45 } ] }, { "description": "INJECT MAJOR JOINT *", "code_information": [ { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 245, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 281, "minimum": 281 } ] }, { "description": "REMOVE,IMPACTED CERUMEN", "code_information": [ { "code": "69210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "OFFICE VISIT,NEW,EXPANDED", "code_information": [ { "code": "99202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 171, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 160, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 64, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 184, "minimum": 184 } ] }, { "description": "PERIOD CMP PRV EXM \u003e65YR", "code_information": [ { "code": "99397", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "TRIMMING OF NAILS ANY NO.", "code_information": [ { "code": "11719", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 139, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 146, "minimum": 146 } ] }, { "description": "PERIOD CMP PRV EXAM 1-4YR", "code_information": [ { "code": "99392", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "PERIOD CMP PRV EXM 12-17Y", "code_information": [ { "code": "99394", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 247, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 242, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 260, "minimum": 260 } ] }, { "description": "HOME VISIT, STRAIGHT, EST", "code_information": [ { "code": "99347", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "DESTRUCT LESIONS \u003e15", "code_information": [ { "code": "17004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 609, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 609, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 609, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 596, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 558, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 641, "minimum": 641 } ] }, { "description": "URINE PREGNANCY TEST", "code_information": [ { "code": "81025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "INIT CMP PRV EXAM 40-64YR", "code_information": [ { "code": "99386", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 316, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 363, "minimum": 363 } ] }, { "description": "PERIOD CMP PRV EXAM \u003c1YR", "code_information": [ { "code": "99391", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 180, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 169, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 68, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 194, "minimum": 194 } ] }, { "description": "PERIOD CMP PRV EXM 5-11YR", "code_information": [ { "code": "99393", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 202, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 189, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 217, "minimum": 217 } ] }, { "description": "SMOKING CESSATION COUNSELING, 3-10 MINS", "code_information": [ { "code": "99406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 82, "minimum": 82 } ] }, { "description": "ADMIN.PNEUMOCOCCAL VAC.", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 97, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 36, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 102, "minimum": 102 } ] }, { "description": "TRIGGER POINTS SINGL/MULT", "code_information": [ { "code": "20552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 259, "minimum": 259 } ] }, { "description": "INIT COMP PRV EXAM 5-11YR", "code_information": [ { "code": "99383", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 261, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 256, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 240, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 275, "minimum": 275 } ] }, { "description": "INIT CMP PRV EXAM 18-39YR", "code_information": [ { "code": "99385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 328, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 321, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 300, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 345, "minimum": 345 } ] }, { "description": "REMOVE,SKIN TAGS TO 15*", "code_information": [ { "code": "11200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 224, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 219, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 83, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 236, "minimum": 236 } ] }, { "description": "INIT COMP PREV EXAM 1-4YR", "code_information": [ { "code": "99382", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 236, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 221, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 89, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 254, "minimum": 254 } ] }, { "description": "INIT COMP PREV EXAM \u003c1YR", "code_information": [ { "code": "99381", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 246, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 241, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 91, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 259, "minimum": 259 } ] }, { "description": "NURSE ONLY VISIT", "code_information": [ { "code": "99211,NV", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "OFFICE VISIT,EST,MINIMAL", "code_information": [ { "code": "99211,OF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 129, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 121, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 49, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 139, "minimum": 139 } ] }, { "description": "SCREENING PAPANICOLAOU SMEAR; OBTAINING, PREPARING AND CONVEYANCE OF CERVICAL OR VAGINAL SMEAR TO LABORATORY", "code_information": [ { "code": "Q0091", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 196, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 184, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 211, "minimum": 211 } ] }, { "description": "I\u0026D ABCESS,COMP OR MUL", "code_information": [ { "code": "10061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 400, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 375, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 151, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 430, "minimum": 430 } ] }, { "description": "REMOVAL OF F.B.EXT EYE *", "code_information": [ { "code": "65205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 179, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 164, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 188, "minimum": 188 } ] }, { "description": "PSYCH FAMILY 1HR", "code_information": [ { "code": "90847", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 390, "minimum": 390 } ] }, { "description": "INIT CMP PRV EXAM 12-17YR", "code_information": [ { "code": "99384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 292, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 286, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 107, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 307, "minimum": 307 } ] }, { "description": "INIT CMP PRV EXAM 65 YO AND OLDER", "code_information": [ { "code": "99387", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 346, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 339, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 317, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 127, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 364, "minimum": 364 } ] }, { "description": "OFFICE VISIT, PHYS EXAM", "code_information": [ { "code": "99212", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "ADM. HEPATITIS B VACCINE", "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 101, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 99, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 92, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 37, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 106, "minimum": 106 } ] }, { "description": "I\u0026D DEEP ABSCESS,SIMPLE*", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 384, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 376, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 404, "minimum": 404 } ] }, { "description": "REMOVE,FOREIGN BODY SIMP*", "code_information": [ { "code": "10120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 259, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 243, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 279, "minimum": 279 } ] }, { "description": "REMOVAL FOREIGN BODY COMP", "code_information": [ { "code": "10121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 361, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 338, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 388, "minimum": 388 } ] }, { "description": "PARING/CUTTING 1 LESION", "code_information": [ { "code": "11055", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 96, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 94, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 101, "minimum": 101 } ] }, { "description": "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE)", "code_information": [ { "code": "11102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 165, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 162, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 152, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 174, "minimum": 174 } ] }, { "description": "VENTOLIN HFA 90 MCG INHALER 90 mcg, 60 dose", "drug_information": { "unit": "90", "type": "EA" }, "code_information": [ { "code": "00173068224", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "EXCISE LESION 1.1-2.0 CM", "code_information": [ { "code": "11602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 784, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 784, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 784, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 767, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 719, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 289, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 825, "minimum": 825 } ] }, { "description": "EXCISE LESION 2.1-3.0 CM", "code_information": [ { "code": "11603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 835, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 835, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 835, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 817, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 766, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 308, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 879, "minimum": 879 } ] }, { "description": "EXCISE LESION 3.1-4.0 CM", "code_information": [ { "code": "11604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 855, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 837, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 784, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 315, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 900, "minimum": 900 } ] }, { "description": "EXCISE,LESION,1.1-2.0CM", "code_information": [ { "code": "11622", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 844, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 826, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 773, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 311, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 888, "minimum": 888 } ] }, { "description": "EXCISE LESION 2.1-3.0", "code_information": [ { "code": "11623", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 874, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 874, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 874, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 856, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 801, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 322, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 920, "minimum": 920 } ] }, { "description": "EXCISE LESION 3.1-4 CM", "code_information": [ { "code": "11624", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1066, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1066, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1066, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1043, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 977, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 393, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1122, "minimum": 1122 } ] }, { "description": "LAYER CLOSURE, \u003c2.5 CM*", "code_information": [ { "code": "12031", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 543, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 543, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 543, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 532, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 498, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 572, "minimum": 572 } ] }, { "description": "LAYER CLOSURE, 2.6-7.5CM*", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 602, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 564, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 226, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 647, "minimum": 647 } ] }, { "description": "LAYER CLOSURE, 7.6-12.5CM", "code_information": [ { "code": "12034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 649, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 635, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 239, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 683, "minimum": 683 } ] }, { "description": "LAYER CLOSURE,12.6-20 CM", "code_information": [ { "code": "12035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 796, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 796, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 796, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 779, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 730, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 838, "minimum": 838 } ] }, { "description": "LAYER CLOSURE, 20.1-30CM", "code_information": [ { "code": "12036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1200, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1175, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1100, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 442, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1263, "minimum": 1263 } ] }, { "description": "LAYER CLOSURE \u003e30.0 CM", "code_information": [ { "code": "12037", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1478, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1478, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1478, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1447, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1355, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1556, "minimum": 1556 } ] }, { "description": "LAYER CLOSURE NECK\u003c2.5 *", "code_information": [ { "code": "12041", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 627, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 614, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 575, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 231, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 660, "minimum": 660 } ] }, { "description": "LAYER CLOSURE 2.6-7.5 CM", "code_information": [ { "code": "12042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 690, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 690, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 690, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 675, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 632, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 254, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 726, "minimum": 726 } ] }, { "description": "LAYER CLOSURE, 7.6-12.5CM", "code_information": [ { "code": "12044", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 720, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 720, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 720, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 705, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 660, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 265, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 758, "minimum": 758 } ] }, { "description": "LAYER CLOSURE 12.6-20.0 CM", "code_information": [ { "code": "12045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 795, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 795, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 795, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 778, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 729, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 293, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 837, "minimum": 837 } ] }, { "description": "LAYER CLOSURE,20.1-30.0 CM", "code_information": [ { "code": "12046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1171, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1147, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1074, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 432, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1233, "minimum": 1233 } ] }, { "description": "LAYER CLOSURE,\u003e30.0 CM", "code_information": [ { "code": "12047", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1270, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1243, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1165, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 468, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1337, "minimum": 1337 } ] }, { "description": "PHALANGEL SHAFT W/O MAL", "code_information": [ { "code": "26720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 302, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 296, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 277, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 111, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 318, "minimum": 318 } ] }, { "description": "THER INJ, IM OR SUBQ", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 63, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 61, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 66, "minimum": 66 } ] }, { "description": "BROTHEL PHYSICAL", "code_information": [ { "code": "99212,BP", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 80, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 78, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 73, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 29, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 84, "minimum": 84 } ] }, { "description": "BROTHEL PHYSICAL W/HIV", "code_information": [ { "code": "99212,BPH", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1361, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1333, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1248, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 502, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1433, "minimum": 1433 } ] }, { "description": "EXCISE LESION \u003e4 CM", "code_information": [ { "code": "11626", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1235, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1209, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 455, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1300, "minimum": 1300 } ] }, { "description": "LAYER CLOSURE FACE \u003c2.5 *", "code_information": [ { "code": "12051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 781, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 781, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 781, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 764, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 716, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 288, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 822, "minimum": 822 } ] }, { "description": "LAYER CLOSURE 2.6-5.0 CM", "code_information": [ { "code": "12052", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 866, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 848, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 794, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 319, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 912, "minimum": 912 } ] }, { "description": "LAYER CLOSURE, 5.1-7.5 CM", "code_information": [ { "code": "12053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1001, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1001, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1001, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 980, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 918, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 369, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1054, "minimum": 1054 } ] }, { "description": "LAYER CLOSURE, 7.6-12.5 CM", "code_information": [ { "code": "12054", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1145, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1121, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1050, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 422, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1205, "minimum": 1205 } ] }, { "description": "LAYER CLOSURE,12.6-20.0 CM", "code_information": [ { "code": "12055", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1326, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1326, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1326, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1298, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1216, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 489, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1396, "minimum": 1396 } ] }, { "description": "LAYER CLOSURE 20.1-30.0 CM", "code_information": [ { "code": "12056", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1378, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1378, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1378, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1348, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1263, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 508, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1450, "minimum": 1450 } ] }, { "description": "LAYER CLOSURE, \u003e30.0 CM", "code_information": [ { "code": "12057", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1449, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1449, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1449, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1418, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1328, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1525, "minimum": 1525 } ] }, { "description": "REPAIR COMX TRUNK 1.1-2.5 CM", "code_information": [ { "code": "13100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1038, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1038, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1038, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1016, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 952, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1093, "minimum": 1093 } ] }, { "description": "REPAIR,COMPLEX 2.6-7.5 CM", "code_information": [ { "code": "13101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1115, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1092, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1023, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 411, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1174, "minimum": 1174 } ] }, { "description": "DESTRUCT WARTS,1-14 *", "code_information": [ { "code": "17110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "DESTRUCT WARTS \u003e15", "code_information": [ { "code": "17111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 203, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 199, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 186, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 214, "minimum": 214 } ] }, { "description": "PSYCH INIT EVAL", "code_information": [ { "code": "90791", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 409, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 383, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 154, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 440, "minimum": 440 } ] }, { "description": "PSYCH 30 MIN", "code_information": [ { "code": "90832", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 142, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 150, "minimum": 150 } ] }, { "description": "PSYCH 45 MIN", "code_information": [ { "code": "90834", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 238, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 232, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 218, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 88, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 250, "minimum": 250 } ] }, { "description": "PSYCH 60 MIN", "code_information": [ { "code": "90837", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 428, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 418, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 392, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 158, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 450, "minimum": 450 } ] }, { "description": "OFFICE VISIT,NEW,HGH COMP", "code_information": [ { "code": "99205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 503, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 461, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 185, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 529, "minimum": 529 } ] }, { "description": "SILVER PEAK EMS", "code_information": [ { "code": "99212,EMR", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 131, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 128, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 120, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 48, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 138, "minimum": 138 } ] }, { "description": "OFFICE CONSULT L1 EST", "code_information": [ { "code": "99212,L1", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "OFFICE CONSULT L2 EST", "code_information": [ { "code": "99212,CS", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 210, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 206, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 192, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 77, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 221, "minimum": 221 } ] }, { "description": "EST OFF VST-LOW COMPLEX", "code_information": [ { "code": "99213,OF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 258, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 272, "minimum": 272 } ] }, { "description": "OFFICE CONSULT L4 EST", "code_information": [ { "code": "99214,CST", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 430, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 421, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 395, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 159, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 453, "minimum": 453 } ] }, { "description": "EST OFF VST-MOD COMPLEX", "code_information": [ { "code": "99214,OF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 276, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 270, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 253, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 102, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 290, "minimum": 290 } ] }, { "description": "EST OFF VST-HIGH COMPLEX", "code_information": [ { "code": "99215,OF", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 545, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 534, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 500, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 201, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 574, "minimum": 574 } ] }, { "description": "MINERAL COUNTY FD PHYS 18-39", "code_information": [ { "code": "99395", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 537, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 492, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 198, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 565, "minimum": 565 } ] }, { "description": "PERIOD CMP PRV EXM 18-39Y", "code_information": [ { "code": "99395", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 267, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 250, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 100, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 287, "minimum": 287 } ] }, { "description": "PERIOD CMP PRV EXM 40-64Y", "code_information": [ { "code": "99396", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 284, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 278, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 105, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 299, "minimum": 299 } ] }, { "description": "SCORPIO GOLD PHYS", "code_information": [ { "code": "99395,MP", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 577, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 565, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 529, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 212, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 607, "minimum": 607 } ] }, { "description": "FLUTICASONE-SALMETEROL 250-50 250 mcg, 60 eaches", "drug_information": { "unit": "250", "type": "UN" }, "code_information": [ { "code": "00054032756", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OCCUPATIONAL STRESS TEST", "code_information": [ { "code": "93015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 380, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 372, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 348, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 400, "minimum": 400 } ] }, { "description": "DUPLEX SCAN UE ARTERIES/ARTIERAL", "code_information": [ { "code": "93930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1349, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1321, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1237, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 497, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1420, "minimum": 1420 } ] }, { "description": "CLEOCIN 150 MG/ML INJECTION 300mg", "drug_information": { "unit": "300", "type": "GR" }, "code_information": [ { "code": "00009087026", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "METHYLPREDNISOLONE 5MG INJECTION", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00009004722", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2919 - INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE 5MG", "drug_information": { "unit": "5", "type": "GR" }, "code_information": [ { "code": "00009075801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM", "code_information": [ { "code": "54220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 740, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 740, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 740, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 725, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 679, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 273, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 779.1, "minimum": 779.1 } ] }, { "description": "PRO FEE; IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM", "code_information": [ { "code": "54220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 306, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 299, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 280, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 322, "minimum": 322 } ] }, { "description": "PREVNAR 20 SYR", "code_information": [ { "code": "90677", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1112, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1088, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1019, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 410, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1170, "minimum": 1170 } ] }, { "description": "SPIKE-VAX 2023-2024 (12^)", "code_information": [ { "code": "91322", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 604, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 604, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 604, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 591, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 554, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 223, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 636, "minimum": 636 } ] }, { "description": "RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL, COMPREHENSIVE", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 204, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 200, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 187, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 75, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 215, "minimum": 215 } ] }, { "description": "ANA, IFA RHEUMATOID ARTHRITIS DIAGNOSTIC PANEL WITH REFLEX TO TITER/PATTERN (QUEST 90071X)", "code_information": [ { "code": "0302", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 352, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 345, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 323, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 130, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 371, "minimum": 371 } ] }, { "description": "CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY IGG", "code_information": [ { "code": "86200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 266, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 260, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 244, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 98, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 280, "minimum": 280 } ] }, { "description": "RHEUMATOID FACTOR", "code_information": [ { "code": "86431", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 72, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 66, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 27, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 76, "minimum": 76 } ] }, { "description": " Injection, bumetanide, 0.5 mg J1939", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "00641600810", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INJECTION, PANTOPRAZOLE SODIUM, 40 MG", "drug_information": { "unit": "40", "type": "GR" }, "code_information": [ { "code": "55150020210", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Venofer-Iron Sucrose 200mg/10ml vial", "drug_information": { "unit": "200", "type": "ML" }, "code_information": [ { "code": "00517231005", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BATA", "code_information": [ { "code": "82075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 143, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 140, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 151, "minimum": 151 } ] }, { "description": "RHOGAM ULTRA-FILTERED PLUS SYR 1500 unit, 1 each", "drug_information": { "unit": "1500", "type": "UN" }, "code_information": [ { "code": "00562780505", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BIOPATHC CHG DIS DRESSING, 1\" DIA., 4 MM HOLE", "code_information": [ { "code": "A6209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 33, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 35, "minimum": 35 } ] }, { "description": "FLUARIX TRIVALENT 2024-25 SYRG 0.5 mcg, 0.5 mL", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "58160088452", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLUAD TRIVALENT HIGH DOSE 2024-2025 SYR 0.5 mcg, 0.5 mL", "drug_information": { "unit": "0.5", "type": "ML" }, "code_information": [ { "code": "70461002403", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1750 - Injection, iron dextran, 50 mg", "drug_information": { "unit": "50", "type": "GR" }, "code_information": [ { "code": "00023608210", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SODIUM CHLORIDE 1 GM TABLET 1 g, 100 eaches", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00904723961", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "niCARdipine 25 MG/10 ML VIAL 1 mcg, 10 mL", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "55150018311", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ROLVEDON 13.2 MG/0.6 ML SYRING 1 mcg, 0.6 mL", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "76961010101", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Dilaudid 1 MG/ML SYRINGE 1 ea, 1 mL", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "76045000911", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FLUARIX TRIVALENT 2024-25 SYRG 0.5 mcg, 0.5 m", "code_information": [ { "code": "90686", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 25, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 26, "minimum": 26 } ] }, { "description": "FLUAD TRIVALENT HIGH DOSE 2024-2025 SYR 0.5 mcg, 0.5 mL", "code_information": [ { "code": "90653", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 62, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 60, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 57, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 65, "minimum": 65 } ] }, { "description": "ALBUTEROL INHALER", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00173068221", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ALBUTEROL .5CC INHALER", "code_information": [ { "code": "J3535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 7, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 3, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 8, "minimum": 8 } ] }, { "description": "PULMICORT RESPULES UNIT DOSE", "code_information": [ { "code": "J3535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 21, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 20, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 19, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 8, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 22, "minimum": 22 } ] }, { "description": "ADVAIR DISKUS 250 MCG-50 MCG/DOSE POWDER FOR INHALATION", "drug_information": { "unit": "14", "type": "UN" }, "code_information": [ { "code": "00173069604", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "PROFEE- PHALNGEAL FRACTURE IN A FINGER OR THUMB", "code_information": [ { "code": "26755", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1255, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1229, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1151, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 462, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1321, "minimum": 1321 } ] }, { "description": "PHALANGEAL FRACTURE IN A FINGER OR A THUMB", "code_information": [ { "code": "26755", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 636, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 622, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 583, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 234, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 669, "minimum": 669 } ] }, { "description": "NON-EMERGENCY TRANSPORTATION: WHEELCHAIR VAN", "code_information": [ { "code": "A0130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1425, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1425, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1425, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1395, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1306, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 525, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1500, "minimum": 1500 } ] }, { "description": "LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE, J2001 - Infusion, PER 10 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "00338041102", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MAGNESIUM SULF 2 G/50 ML BAG 500 mg, 50 mL", "drug_information": { "unit": "500", "type": "GR" }, "code_information": [ { "code": "00409672924", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "I\u0026D of Ischiorectal and/or perirectal abcess - ProFee", "code_information": [ { "code": "46040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1089, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1089, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1089, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1066, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 998, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 401, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1146, "minimum": 1146 } ] }, { "description": "I\u0026D of Ishiorectal and/or perirectal abcess", "code_information": [ { "code": "46040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1915, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1915, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1915, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1875, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1756, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 706, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 2016, "minimum": 2016 } ] }, { "description": "J2997 - INJECTION, ALTEPLASE RECOMBINANT, 1 MG", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "50242004413", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE", "code_information": [ { "code": "82785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 138, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 135, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 126, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 51, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 145, "minimum": 145 } ] }, { "description": "\tALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH", "code_information": [ { "code": "86003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 76, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 28, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 80, "minimum": 80 } ] }, { "description": "J1644 - INJECTION, HEPARIN SODIUM, PER 1000 UNITS", "drug_information": { "unit": "1000", "type": "UN" }, "code_information": [ { "code": "25021040201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "BANOPHEN ANTI-ITCH 2% CREAM 28 g, 28 g", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "00904535431", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "69547062702", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SWING BED", "code_information": [ { "code": "0550", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1615, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1581, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1481, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 595, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1700, "minimum": 1700 } ] }, { "description": "PRO_FEE REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL", "code_information": [ { "code": "69209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 46, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 45, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 17, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 48, "minimum": 48 } ] }, { "description": "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL", "code_information": [ { "code": "69209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 116, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 113, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 106, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 122, "minimum": 122 } ] }, { "description": "PIOGLITAZONE HCL 15 MG TABLET 15 mcg, 30 eaches", "drug_information": { "unit": "15", "type": "UN" }, "code_information": [ { "code": "65862051230", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FULVESTRANT 250 MG/5 ML SYRING 25 mg, 5 mL", "drug_information": { "unit": "25", "type": "GR" }, "code_information": [ { "code": "16714007002", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J3010 - Injection, fentanyl citrate, 0.1 mg", "drug_information": { "unit": "0.1", "type": "ML" }, "code_information": [ { "code": "00409909332", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "fentaNYL 100 MCG/2 ML VIAL 0.1 mcg, 2 mL", "drug_information": { "unit": "0.1", "type": "ML" }, "code_information": [ { "code": "00409909422", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "FAMOTIDINE 20 MG/2 ML VIAL 0.25 mg, 2 mL", "drug_information": { "unit": "0.25", "type": "ML" }, "code_information": [ { "code": "67457043322", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OMNIPAQUE 300 MG/ML, IV CONTRAST UP TO 100 CC", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "00407141363", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1940 - Injection, furosemide, up to 20 mg", "drug_information": { "unit": "20", "type": "GR" }, "code_information": [ { "code": "00409610204", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HH ILG HOMEMAKER 1 HOUR", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "HH ILG HOMEMAKER 0.25 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 6, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 2, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 6.25, "minimum": 6.25 } ] }, { "description": "INJECTAFER 750 MG/15 ML VIAL 1 mcg, 15 mL", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "00517065001", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "HH ILG HOMEMAKER 0.5 HOURS", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 12.5, "minimum": 12.5 } ] }, { "description": "J1953 - INJECTION, LEVETIRACETAM, 10 MG", "drug_information": { "unit": "10", "type": "ML" }, "code_information": [ { "code": "25021078005", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "AZITHROMYCIN I.V. 500 MG VIAL 500 mcg, 1 each", "drug_information": { "unit": "500", "type": "UN" }, "code_information": [ { "code": "63323039810", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2270 - Injection, morphine sulfate, up to 10mg", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "00641612725", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "T\u0026D - URINE DRUG COLLECTION", "code_information": [ { "code": "99001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 45, "minimum": 45 } ] }, { "description": "T\u0026D - ALCOHOL; BREATH", "code_information": [ { "code": "82075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 71, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 70, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 65, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 26, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 75, "minimum": 75 } ] }, { "description": "J3480 - Injection, potassium chloride, per 2 meq", "drug_information": { "unit": "2", "type": "UN" }, "code_information": [ { "code": "63323096510", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "POTASSIUM CL 40 MEQ/20 ML CONC 2 mcg, 20 mL", "drug_information": { "unit": "2", "type": "UN" }, "code_information": [ { "code": "63323096520", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "SNF ROOM", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 522, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 512, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 479, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 193, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 550, "minimum": 550 } ] }, { "description": "SELF-PAY SNF ROOM", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 370, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 363, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 340, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 136, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 390, "minimum": 390 } ] }, { "description": "CEFTRIAXONE 1 GM/VIAL, J0696 - INJECTION, PER 250 MG", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "60505075204", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "CEFTRIAXONE 250 MG/VIAL, J0696 - INJECTION, PER 250 MG", "drug_information": { "unit": "250", "type": "GR" }, "code_information": [ { "code": "00409733201", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NovoLIN N 100 UNIT/ML VIAL 5 unit, 10 mL", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00169183411", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "70-30 INSULIN (HUMULIN 70-30), J1815 - INJECTION, ER 5 UNITS", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00002871501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "EPINEPHrine 1 MG/10 ML LUERJET 0.1 mcg, 10 mL", "drug_information": { "unit": "0.1", "type": "GR" }, "code_information": [ { "code": "76329331801", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J0171 - Injection, adrenalin, epinephrine, 0.1 mg", "drug_information": { "unit": "0.1", "type": "GR" }, "code_information": [ { "code": "76329331601", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "NOREPINEPHRINE INJECTION 4MG/4ML", "drug_information": { "unit": "0.1", "type": "ML" }, "code_information": [ { "code": "67457085204", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "ADRENALIN 1 MG/ML VIAL 0.1 mcg, 1 mL", "drug_information": { "unit": "0.1", "type": "UN" }, "code_information": [ { "code": "42023015925", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Optifoam Dressing 5x5", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 12, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 11, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 5, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 13, "minimum": 13 } ] }, { "description": "OPTIFOAM DRESSING 3X3", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 10, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 4, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 11, "minimum": 11 } ] }, { "description": "OPTIFOAM DRESSING 6X6", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 24, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 23, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 22, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 9, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 25, "minimum": 25 } ] }, { "description": "J2310 - Injection, naloxone hydrochloride, per 1 mg", "drug_information": { "unit": "1", "type": "GR" }, "code_information": [ { "code": "76329336901", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "Tues Wellness; CMP, CBC, A1C, TSH, LIPID", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 81, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 79, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 74, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 30, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 85, "minimum": 85 } ] }, { "description": "Tues Wellness; CMP, CBC, A1C, LIPID, TSH, PSA", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 95, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 93, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 87, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 35, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 100, "minimum": 100 } ] }, { "description": "APLISOL (PPD/TB TEST) 0.1 ML/DOSE, 86580 - INTRADERMAL INJECTION SOLUTION", "drug_information": { "unit": "0.1", "type": "ML" }, "code_information": [ { "code": "42023010401", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "GLIADIN ANTIBODY (IGG, IGA)", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "LANTUS INSULIN/VIAL, J1815 - INJECTION, PER 5 UNITS", "drug_information": { "unit": "5", "type": "UN" }, "code_information": [ { "code": "00088222033", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INJECTION, VEDOLIZUMAB, INTRAVENOUS, 1 MG", "drug_information": { "unit": "1", "type": "UN" }, "code_information": [ { "code": "64764030020", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "INJECTION, CALCIUM GLUCONATE (WG CRITICAL CARE), NOT THERAPEUTICALLY EQUIVALENT TO J0612, 10 MG", "drug_information": { "unit": "10", "type": "GR" }, "code_information": [ { "code": "44567062024", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "63323036501", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "COVID-19 RAPID ANTIGEN (BINAX) -- MGGH LAB", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 43, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 42, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 39, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 16, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 45, "minimum": 45 } ] }, { "description": "COVID-19 RAPID ANTIGEN (IN-HOUSE) -- MGGH LAB", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 144, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 141, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 132, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 53, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 152, "minimum": 152 } ] }, { "description": "J3360 - Injection, diazepam, up to 5 mg", "drug_information": { "unit": "5", "type": "ML" }, "code_information": [ { "code": "00409127332", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1885 - INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "63323016212", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1885 - INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG", "drug_information": { "unit": "30", "type": "ML" }, "code_information": [ { "code": "72266011925", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J1885 - INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG", "drug_information": { "unit": "15", "type": "ML" }, "code_information": [ { "code": "72266011825", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "J2405 - INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "00641607825", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] }, { "description": "MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION", "drug_information": { "unit": "1", "type": "ML" }, "code_information": [ { "code": "00009737611", "type": "NDC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Anthem Blue Cross", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Anthem Blue Cross" }, { "payer_name": "Hometown Health", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Hometown Health" }, { "payer_name": "Prominence", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 95, "methodology": "percent of total billed charges", "plan_name": "Prominence" }, { "payer_name": "Silver Summit", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 93, "methodology": "percent of total billed charges", "plan_name": "Silver Summit" }, { "payer_name": "Aetna", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 87.1, "methodology": "percent of total billed charges", "plan_name": "Aetna" }, { "payer_name": "Aetna W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Aetna W/ Medicare Advantage" }, { "payer_name": "Optumcare W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Optumcare W/ Medicare Advantage" }, { "payer_name": "Humana W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Humana W/ Medicare Advantage" }, { "payer_name": "Healthplan Nevada W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Healthplan Nevada W/ Medicare Advantage" }, { "payer_name": "Sierra Health and Life W/ Medicare Advantage", "negotiated_type": "percentage", "estimated_amount": 1, "standard_charge_percentage": 35, "methodology": "percent of total billed charges", "plan_name": "Sierra Health and Life W/ Medicare Advantage" } ], "maximum": 1, "minimum": 1 } ] } ] }